Respiratory
Inpatient hospital

Diagnosis: COPD
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a man with antiphospholipid syndrome, chronic obstructive pulmonary disease (COPD), cerebrovascular accident (CVA) with left-sided weakness and speech impairment, gout, diabetes, hypertension, chronic kidney disease and aortic valve vegetation who presented to the hospital with a chief complaint of shortness of breath and chest tightness which started several days earlier. Vital signs showed temperature 97.4 Fahrenheit, heart rate 92, and blood pressure 143/83. Oxygen saturation was 96%. On physical exam, heart was regular, breath sounds were normal with no wheezes, and the abdomen was soft and nontender. The patient was admitted with suspected COPD exacerbation. The plan of care included steroids, bronchodilators, renal consult, monitor kidney function, Renal ultrasound, sodium bicarbonate for metabolic acidosis, and continue other home medications. The pulmonary service saw the patient and assisted with management of COPD.

The inpatient hospital admission was not medically necessary.

The patient was admitted for chest pain and suspected ACS (acute coronary syndrome) along with suspected COPD exacerbation. However, he was hemodynamically stable, was not hypoxic, did not have acute electrocardiogram (EKG) abnormalities or respiratory distress, and had no other complicating factors such as involvement of the aortic valve vegetation. His hospital stay was relatively stable and of low acuity. He did not need an inpatient level care.

The patient was hemodynamically stable and although he was seen by cardiology and pulmonary specialists, he was never acutely ill or in respiratory distress, based on the description of symptoms and the reported physical exam findings in progress notes. In addition, there was no evidence of pneumonia or sepsis. Overall, this was a stable hospital stay and the treatment plan could have been provided safely and effectively at a lower level of care.