Diagnosis: Asthma flare
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of asthma (no prior intubations), hypertension (HTN), and prior cerebrovascular accident (CVA) presented with 2 days of worsening dyspnea, cough, and wheeze. He was given nebulized albuterol by Emergency Medical Services (EMS) and had some improvement.
In the emergency department (ED), his temperature was 98.6 degrees Fahrenheit, blood pressure (BP) 117/99, heart rate (HR) 107, respiratory rate (RR) 22, peripheral capillary oxygen saturation (SpO2) 97% (percent) on room air (RA). He was not in distress, was breathing comfortably, wheezy, alert and oriented. His sodium (Na) was 138, bicarbonate 24, blood urea nitrogen (BUN)/creatinine (Cr) 14/1.0. A chest x-ray (CXR) showed a subtle left lower lobe (LLL) opacity. He was given nebulized bronchodilators and systemic steroids and continued to improve while in the emergency department (ED) though he still had some wheeze. His CXR findings prompted a consideration of pneumonia, so ceftriaxone and azithromycin were given.
He was diagnosed with an asthma flare possibly due to pneumonia and started on intravenous (IV) methylprednisolone, ceftriaxone, azithromycin, and nebulized bronchodilators.
The next day he was noted to have clear lungs on exam, was saturating well on room air (RA), and treatments continued. He continued to do well, and treatments were continued. He was discharged on Augmentin.
At issue is the medical necessity of inpatient stay.

An inpatient admission was not medically necessary. The patient presented with pneumonia and an asthma exacerbation. He was not severely ill at presentation with no encephalopathy, hemodynamic instability, respiratory distress or marked gas exchange abnormality, or acute kidney injury or marked electrolyte abnormality. He was not at high risk with no history of severe asthma or prior intubation. From a pneumonia standpoint, as above, he was not severely ill. Routine scoring systems would suggest a low risk of worsening or needing intensive care unit (ICU) care. For both pneumonia and asthma he seemed to improve and by the next day, no wheezing was described on exam; subjective wheezing was described, though his exam was normal. He was not in respiratory distress and was saturating well on room air (RA).
As he was not severely ill, was at low risk of worsening from an asthma or pneumonia standpoint, and improved, an inpatient admission was not medically necessary.