Respiratory System - Breathing Problem
Inpatient Hospital

The patient has a history of chronic obstructive pulmonary disease (COPD), hypertension, tobacco abuse, schizoaffective disorder, opioid dependence, and alcohol dependence. He presented to the emergency room with a one-day history of shortness of breath. The vital signs were unremarkable, including a normal respiratory rate, but the physical exam was notable for labored breathing and diffuse wheezes. His lab work was notable for arterial blood gases documenting minimal carbon dioxide (CO2) retention but there was also an elevated serum bicarbonate. The electrocardiogram (EKG) and chest x-ray were non-contributory. The cardiology consultant evaluated the patient and concluded that the patient was suffering from an exacerbation of COPD, with an element of noncompliance. Nebulizer treatments were administered in the emergency room. The patient was admitted for further treatment and evaluation. Upon admission, the patient was treated with his usual home regimen, intravenous corticosteroids, intravenous antibiotics, and nebulizer treatments. The clinical course was uneventful, and the patient signed out against medical advice.

The health plan's determination of medically necessity is upheld in whole.

The health plan, in its determination of medical necessity, has acted reasonably, with sound medical judgment, and in the best interest of the patient. The requested health service/treatment of inpatient stay was not medically necessary for this patient. Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints. There is no evidence that he required intravenous corticosteroids or intravenous antibiotics. The services provided could have easily and safely provided in the emergency room or an observation stay. Based on the standard of care and peer reviewed literature, the inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.