Diagnosis: Trouble Breathing
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult female. She presented to the emergency room with worsening shortness of breath. The patient has history of COPD (chronic obstructive pulmonary disease) and was noticed to have low oxygen levels at home.

In the ER (emergency room), the patient was hypoxic and was placed on supplemental oxygen, IV (intravenous) steroids, nebulization and antibiotics. The patient was admitted to acute inpatient level of care for the management of COPD (chronic obstructive pulmonary disease) exacerbation.
The acute inpatient hospitalization was denied coverage by the
health plan due to lack of medical necessity. This denial is being appealed.

The Inpatient Hospital Admission was not medically necessary.

The patient was admitted to acute inpatient level of care for 3 days for COPD (chronic obstructive pulmonary disease) exacerbation. At the time of admission, the patient was
hemodynamically stable. The patient was not in severe respiratory distress. The patient's respiratory status had improved with ER (emergency room) care. The patient was able to ambulate and tolerate oral diet. The acute inpatient admission was not medically necessary. Given that the patient's signs and symptoms due to COPD (chronic obstructive pulmonary disease) exacerbation improved significantly with ER (emergency room) care, the patient's treatment course would have been expected to be safe and effective at a lower level of care. The treatment provided in this patient was reasonably expected to be provided but does not require an acute inpatient level of care.