This is a patient with a diagnosis of chronic obstructive pulmonary disease. The denied treatment is an inpatient level of care.

The patient has a history of chronic obstructive pulmonary disease, chronic respiratory failure on 2 liters (L) of oxygen at home, obesity, congestive heart failure, obstructive sleep apnea, and hypertension, who presented to the emergency department with shortness of breath, chest tightness, wheezing, and an episode of pre-syncope.
On presentation, the patient was afebrile with a blood pressure 106/72, heart rate 80, respiratory rate 18, and oxygen saturation 96% on an unknown amount of oxygen. The exam otherwise noted the patient to be using accessory muscles without wheezing, crackles or rhonchi noted. Labs resulted with white blood cell count (WBC) 7.1, Hemoglobin (HGB) 13.9, Platelets 178, sodium (NA) 144, potassium (K) 4.2, blood urea nitrogen (BUN) 10.5, creatinine 1.17, and arterial blood gas (ABG) with potential of hydrogen (pH) 7.37/ partial pressure of carbon dioxide (pCO2) 42.8 /partial pressure of oxygen (pO2) 67 on an unclear amount of oxygen. A urinalysis did not show evidence of an acute infection. A chest x-ray showed no clear evidence of cardiopulmonary disease. An electrocardiogram (EKG) revealed no acute ischemia or arrhythmia. A computed tomography (CT) scan of the cervical spine showed reversal of the normal lordotic curvature with degenerative change with mild canal stenosis at the level of cervical (C) 4-C5 and no evidence of an acute fracture. The patient was brought into the hospital with concerns for pre-syncope with chest pain and associated shortness of breath with her noted to look comfortable and with no concern for acute chronic obstructive pulmonary disease (COPD) exacerbation. The plan was for serial troponins, telemetry, echocardiogram, carotid ultrasound, neurology consultation, and continuing nebulizers and home medications.
The patient remained hemodynamically stable. She signed out against medical advice with her carotid doppler and echocardiogram results pending.

The health plan's determination is upheld.
This is a patient with chronic respiratory failure on home oxygen who presented with dizziness and near syncope. She was afebrile with hypotension or tachycardia on presentation and remained hemodynamically stable throughout her course. She furthermore had no arrhythmia on presentation, no recurrent syncope, and there was no concern for acute coronary syndrome contributing to near syncope, with the patient otherwise also having normal labs. She was otherwise noted to have a history of COPD without evidence of acute exacerbation. It is unclear why, in the face of presenting with near syncope and dizziness, with hemodynamic stability throughout her course and unremarkable labs with no ongoing pre-syncope or syncope after presentation, this patient was not safe to care for at a lower level of care. Pre-syncope/syncope is almost always cared for as an outpatient diagnosis. Inpatient care was not medically necessary.