Diagnosis: shortness of breath.
Treatment: Inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a man with history of asthma who presented to the hospital. He presented with a chief complaint of shortness of breath. He denied fevers, chills, nausea and vomiting. Other past history included bipolar disorder, heroin abuse and personality disorder. Vital signs showed Blood pressure 132/68, heart rate 80, temperature 97.9 Fahrenheit, and respiratory rate 20. On physical examination, heart was regular, breath sounds had wheezes but no crackles, abdomen was soft, and there was no cranial nerve deficit. Chest x-ray was negative for pneumonia. Labs showed white blood cell count (WBC) 12.4, hemoglobin 14.2, platelets 159, creatinine 0.73, sodium 139, and potassium 4.8. The patient was admitted for acute asthma exacerbation in the setting of drug use. The plan of care included bronchodilators, azithromycin, prednisone, pulmonary function testing, brain (or B-type) natriuretic peptide (BNP) testing, D dimer, consider chest computed tomography (CT), COVID-19 testing, and outpatient pulmonary consult.

The inpatient hospital admission was not medically necessary. The patient presented with shortness of breath but he was hemodynamically stable, had a normal oxygen saturation, had a negative chest x-ray with no evidence of acute pneumonia, did not have evidence of sepsis, and overall was stable. Inpatient care was not needed to evaluate his symptoms.

The patient did have risk factors for a potentially adverse outcome, particularly because of his history of heroin use. However, he demonstrated improvement within the first 24 hours, with a reduction in dyspnea and overall symptoms. In addition, he did not have hypoxemia. Given rapid improvement in 24 hours, albeit still in a state requiring additional medical care, he could have been managed at a lower level of care.