Diagnosis: Asthma.

Treatment: Inpatient stay.

The insurer denied coverage for inpatient stay. The denial is upheld.

This patient is a male with history of asthma. The patient presented to the Emergency Department (ED) with a prior two day history of cough, wheezing and shortness of breath. The patient's cough was productive of clear sputum. The patient denies fever, chills, and chest pain. The patient did not respond to his home inhalers and nebulizer so came to the ED. In the ED Vital Signs (V/S) were temperature (T) 97.4 F, blood pressure (BP) 134/92 mm Hg, heart rate (HR) 109, respiratory rate (RR) 18 and oxygen (O2) saturations 93 %. The patient was in no acute distress. Pulmonary effort was normal. Wheezing and rhonchi were reported. The patient's peak expiratory flow (PEF) before treatment was 350 LPM. The patient was treated with intravenous (IV) steroids, bronchodilator via nebs and given empiric antibiotics. The patient was noted to be feeling better after treatment in the ED. The patient was described as ambulatory.

Labs at presentation were white blood cell (WBC) count 9.1 K, hemoglobin (Hb) 15.6 and electrolytes were within normal limits. Chest x-ray showed no acute infiltrates. The patient was admitted to the hospital for asthma exacerbation. As per History & Physical vital signs were T 97.5 F, HR 98, RR 20, BP 130/71 mm Hg and O2 saturations 93%. The patient was in no acute distress. Bilateral wheezing is noted. Cardiovascular system was normal. The patient was alert and oriented x3. Labs were as above. The patient was breathing more comfortably post treatment. As per a note the patient was afebrile and hemodynamically (HD) stable. Oxygen saturations were 98%. The patient was in no acute distress. Lungs were described as clear. Abdomen was soft and non-tender (NT). The patient was awake and alert X 3. Neurological exam was within normal limits. White blood cell (WBC) count was 7.5 K. Electrolytes were within normal limits.

This patient did not need acute inpatient hospitalization. He had improved after treatment in the ED. The patient was awake and alert. The patient was ambulatory. He was not hypoxic. There was no evidence of pneumonia on chest x-ray. PEFR was 350 before Rx.

This patient could have been placed in Observation status while diagnostic testing and treatment were initiated. The patient improved following treatment. By a specified date the patient was afebrile and hemodynamically stable. Lungs were clear. Oxygen saturations were 98%. The plan was to taper steroids. Antibiotics were discontinued as no pneumonia was noted. This patient was stable to be discharged home on oral steroids and bronchodilators and other asthma and maintenance medications with close follow-up in an outpatient setting.

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

The carrier's denial of coverage for the inpatient stay is upheld. The medical necessity is not substantiated.