Diagnosis: Asthma exacerbation / community acquired pneumonia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

This is an elderly patient with a past medical history of asthma, atrial fibrillation, diabetes, hyperlipidemia, and hypertension. The patient presented to the emergency department (ED) with a 5 day history of chills, congestion, shortness of breath (SOB), wheezing and productive cough. The patient was ambulatory upon arrival to the ED. Initial vital signs were Temperature 97.5 degrees Fahrenheit, Heart Rate 63, Respiratory Rate 20, Blood Pressure (BP) 131/62 and oxygen saturation 100% on room air. The patient was in no acute distress. Lung exam revealed coarse breath sounds and bilateral wheezes. Heart sounds were normal. The patient was alert and oriented x 3 with a non-focal neurologic exam.

White Blood Cell count (WBC) was 5,200. Hemoglobin 14.3, Other labs were within normal limits. Chest x-ray showed faint opacities of the right lower lobe, possibly pneumonia. The patient was admitted with diagnoses of asthma exacerbation/ community acquired pneumonia.

This patient was treated with intravenous (IV) steroids, bronchodilators, and placed on antibiotics - Rocephin and Azithromycin. The patient remained stable after admission, was afebrile, not hypoxic and hemodynamically stable. The patient was ambulatory and tolerating food and fluids. The patient was discharged home on oral antibiotics, steroids and other maintenance meds.

This patient did not need acute inpatient hospitalization. He could have been placed in observation status while diagnostic testing and treatment were initiated. The observation period could be for up to 48 hrs. Patient was afebrile, stable and tolerating food and fluids. Oxygen saturations remained 98-100 % on room air. The patient had mild pneumonia, if present, with low pneumonia severity index (PSI) and CURB 65 (confusion, uremia, respiratory rate, BP, age >= 65 years) score of 1. His asthma was also mild and responded well to ED treatment. Patient could have been placed in observation initially and switched to oral antibiotics and oral steroids and bronchodilators after a period under observation, as he was quite stable overall. The patient could have been discharged home after a period in observation (which could be up to 48 hours) on oral medications with close follow-up in the outpatient setting.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for the inpatient is not substantiated.