Diagnosis: Acute Hypoxic Respiratory Failure
Treatment: Full hospital admission
The insurer denied coverage for full hospital admission.
The denial is upheld.

The patient is a male with history of primary lateral sclerosis (PLS) and chronic obstructive pulmonary disease (COPD), who presented to the emergency department (ED) with complaint of weakness and shortness of breath (SOB). The patient had been seen in ED for chronic back pain. He was discharged home on oral (PO) pain meds. The patient had fallen from his bed and was not able to get up. He denied any fever or cough. The patient was on Baclofen and Nuedexta for PLS.

Vital signs at presentation included temperature 97.6 Fahrenheit, heart rate (HR) 77, respiratory rate (RR) 18, blood pressure (BP) 123/71 mm Hg (millimeters of mercury), and oxygen (O2) saturation 95% (percent) on 2L (liters) nasal cannula (NC). The patient was in no acute distress (NAD). Lungs were clear, cardiovascular system (CVS) had normal S1 (first heart sound), S2 (second heart sound) heart sounds. The patient was alert and oriented to person, place, and time. He had weakness in lower extremities (LE). Motor strength of upper extremities (UE) was 5/5. LE 3/5. White blood cell (WBC) count was 8.7, hemoglobin (Hgb) was 12, electrolytes were within normal limits (WNL), blood urea nitrogen (BUN)/Creatinine (Cr) 37/1.1. Imaging studies revealed infiltrates/atelectasis in left lobe. The patient was admitted for pneumonia and started on Rocephin and Azithromycin.

Repeat vital signs were temperature 98.8, HR 78, RR 18, BP 142/97 mm Hg, and O2 saturations 98%. The patient was in NAD. Lungs were clear. WBC 9, BUN/Cr 28/1.0. The patient was tolerating PO (oral).

The patient remained stable after admission and was discharged home on PO medications.

This patient did not need acute inpatient hospitalization. He could have been placed in observation status while diagnostic testing and treatment were initiated. Observation period could be for up to 48 hours. This patient remained afebrile and hemodynamically stable. The patient was requiring minimal O2 if any. He was tolerating PO. WBC was normal.

The patient's pneumonia was mild. The patient's pneumonia severity index (PSI) was low. CURB65 (confusion, uremia, respiratory rate, BP, age > [greater then] 65 years) score was 1. The patient's BUN improved after hydration. The patient was able to hydrate PO.

This patient was stable to be discharged home on PO antibiotics, pain meds and his maintenance medications for PLS after a period in observation.

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is upheld. Medical necessity is not substantiated.