Diagnosis: Bronchitis.
Treatment: Inpatient admission.

The insurer denied the inpatient admission. The denial was overturned.

This is a young female patient who presented to the Emergency Department (ED) after being seen by her primary care provider for fever, cough and difficulty breathing. The patient was treated with nebulized albuterol and Tylenol at home. It was reported that the patient had had a similar episode a few months ago where she was treated with albuterol. In the ED, the patient was noted to appear tired with significant increase in her work of breathing. On exam it was noted that the patient had rales, wheezing and was experiencing subcostal retractions, tachycardia, and tachypnea; her respiratory rate was 48 breaths per minute. The patient was given oxygen, an intravenous (IV) fluid bolus and Orapred. Laboratory work up was done that revealed a white blood cell (WBC) count of 18,200. The patient's respiratory distress did not improve with the treatment in the ER; she was admitted for observation. The patient's breathing rate remained elevated; 50 breaths per minute. It was determined that she had bronchitis. She was admitted to the hospital for further medical treatment. She was treated with albuterol every 2 hours. After several days of treatment she was medically stable and discharged home.

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. The patient was treated appropriately in the Emergency Room (ER) for respiratory distress with rales and wheezing. The patient's tachypnea, retractions with increased work of breathing did not respond to treatment in the ER. The decision to admit to the hospital for ongoing treatment with IV fluids, albuterol and oxygen was appropriate and consistent with the standard of care. The patient had also trailed observation level of care but due to her need for more frequent albuterol treatment and close monitoring, the patient was admitted to inpatient level of care.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient stays should be overturned. The medical necessity is substantiated.