Diagnosis: Difficulty Breathing.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with a diagnosis of moderate to severe persistent asthma. He was admitted to the hospital.

The health plan denied coverage for the inpatient admission on the basis that it lacked medical necessity. This denial is being appealed.

No, the Inpatient admission was not medically necessary.
The patient presented to the ED (emergency department) with 4 day onset of rhinorrhea, nasal congestion, dry cough, and poor appetite. For the two hours prior, the patient had been having trouble breathing and "air hunger." Physical exam noted that the patient was ill-appearing and had moderate respiratory distress with low-grade fever and borderline tachycardia. Diffuse wheezing, tachypnea, retractions, and decreased breath sounds were also noted. The patient was diagnosed with bronchiolitis associated with moderate bronchospasm and signs of moderate respiratory distress. He was given 3 Duo Nebs and Solumedrol. He responded to the treatments and IV (intravenous) fluids. Mild breathing effort remained but the patient's breathing and retractions improved. He was noted to be speaking to his parents. Oxygen saturation was 100%. It is not clear why the patient was transferred and admitted, given his improvement in the ED (emergency department).

In an appeals letter, it was noted that the patient "was admitted immediately and started on albuterol every 2 hours. This asthma pathway regimen continued with continuous reassessing for the need for nebulizer treatment. As the plan of care continued, there were no noted acute events overnight. With noted clinical improvement, he was discharged to home on albuterol nebulizer treatments every four hours as needed for any shortness of breath or wheezing." However, the provided clinic notes do not corroborate the veracity of these statements.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The documentation provided does not justify the hospitalization, given the patient's improvement in the ED (emergency department).