Diagnosis: Respiratory System (Asthma)
Treatment: Inpatient Hospital

Summary: This patient with history of asthma presented to the Emergency Department (ED) with a complaint of shortness of breath. The patient also reported some cough, chills, sweating and one episode of vomiting. The patient did not obtain relief from his rescue inhaler and Symbicort; therefore, he came to the ED. The patient's past medical history included gastroesophageal reflux disease and hypertension. The patient had been recently treated for pneumonia five weeks ago for which he was treated with antibiotics and steroids. Vital signs at presentation to the ED included a temperature of 98.8°F, a heart rate of 110, a respiratory rate of 28, and a blood pressure of 169/130 mm Hg. Oxygen saturations were 94% on room air. Lung exam revealed bilateral wheeze. The patient was treated with intravenous (IV) steroids and nebulizers in the ED. The patient also received magnesium. The white blood cell (WBC) count was 12.4K. The hemoglobin was 17 and the hematocrit was 52.8. Blood urea nitrogen (BUN)/Creatinine levels were 18/1.52. An influenza screen was negative. A chest x-ray showed no acute infiltrates. The patient was admitted and treated with IV fluids, IV steroids, and DuoNebs. Hydrochlorothiazide was held as the patient was clinically dry. As per the history & physical, the patient was in no acute distress. Peak expiratory flow (PEF) after treatment was 400. A lung exam revealed mild expiratory wheeze in the upper lobes. Cardiovascular heart sounds were S1 S2 normal. The abdomen was soft, nontender, and with positive bowel sounds.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

This patient had a mild asthma exacerbation which was improving after treatment in the ED. The patient had possible mild acute kidney injury secondary to dehydration (the patient was also on hydrochlorothiazide) for which he was receiving IV hydration. As per the history & physical, discharge was anticipated in 12-24 hrs. This patient did not need acute hospitalization. He could have been placed in observation while diagnostic testing and treatment were being initiated. The patient could have received oral and IV hydration in observation status. The patient improved with treatment. He remained afebrile and hemodynamically stable. PEF was 400 after treatment. He was tolerating oral intake. There was no pneumonia or influenza. The patient was not hypoxic. He was stable for discharge on oral medications and inhalers with close follow-up in an outpatient setting. The medical necessity is not substantiated.