Diagnosis: Chronic Obstructive Pulmonary Disease (COPD)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Upheld

The patient is a female with a past medical history significant for chronic obstructive pulmonary disease (COPD), tobacco use disorder, hypertension, type 2 diabetes mellitus, hyperlipidemia, seizure disorder, bipolar disorder, schizophrenia, and anxiety who presented to the emergency department with complaints of shortness of breath and productive cough. The patient had a small amount of whitish sputum. She also endorsed associated chest tightness at times, not related to activity or cough. The review of systems was negative for fever, chills, rigors, palpitations, sweating, and lightheadedness.

The patient was admitted to the hospital with a diagnosis of acute respiratory distress secondary to chronic obstructive pulmonary disease (COPD) exacerbation, hypomagnesemia, hypercalcemia, and lactic acidosis that was attributed to recently initiated treatment with metformin. During the hospital stay, the patient received treatment with intravenous fluids due to lactic acidosis. The treatment with metformin was discontinued. During the hospital stay, the patient remained afebrile and hemodynamically stable. She was discharged home the next day after admission.

The health plan's determination is upheld.

The inpatient hospital admission was not medically necessary for this patient. The patient presented to the hospital with complaints of shortness of breath and a productive cough. The patient was hemodynamically stable and had a respiratory rate of 18 breaths/minute and oxygen saturation of 98% on room air. This patient likely had mild COPD exacerbation. During the hospital stay, the patient's respiratory rate remained normal, and she never required supplemental oxygen. Furthermore, on the physical exam, the patient was in no respiratory distress, had no rales, rhonchi, or wheezing, and did not use accessory muscles. The chest x-ray did not demonstrate any infiltrates or effusions.
This patient had lactic acidosis, which was most likely related to the use of Metformin. The treatment of lactic acidosis required discontinuation of Metformin and hydration. This patient had hypomagnesemia that was not critical and could have been repleted overnight. Taking into consideration all these facts, the admission at a lower level of care status was the most appropriate, given the clinical circumstances.