Diagnosis: Acute asthma exacerbation due to influenza infection.
Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission. The denial is upheld.

This is a female patient with a history of asthma, transient ischemic attack (TIA), and renal stones who presented to the emergency department (ED) with a complaint of coughing, pleuritic chest pain, and hemoptysis. Her vital signs were: temperature 98 F, blood pressure 142/72 mm Hg, heart rate 102, respiratory rate 20, and oxygen saturation 100% on room air. The patient was in no acute distress, speaking in full sentences, was awake, alert and oriented.

Physical examination revealed lungs with vesicular breath sounds and bilateral expiratory wheezing. Cardiovascular systems were normal. A chest x-ray showed no acute infiltrates. Influenza A was positive. The patient was treated with intravenous steroids, bronchodilators, magnesium, azithromycin, and Tamiflu. She was admitted to the hospital with an asthma exacerbation, was not hypoxic, was afebrile, and hemodynamically stable. This patient did not need acute hospitalization. There was subjective improvement after bronchodilation in the emergency department, but wheezing persisted. The patient was ambulating, in no acute distress, tolerating oral intake, remained stable, and there was no further hemoptysis. The patient was discharged in 2 days.

This patient could have been placed on observational status while diagnostic testing and treatment were initiated. She could have been discharged home on oral antibiotics, oral steroids, and other maintenance asthma medications after a period of observation with close follow-up outpatient.

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

The medical necessity for the inpatient hospital is not substantiated. The insurer's denial is upheld.