Diagnosis: Asthma

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld


The patient is an adult who was admitted to the hospital with complaints of shortness of breath (SOB). The patient was admitted for asthma exacerbation. The patient was afebrile, in no acute distress, and hemodynamically stable. Lung exam revealed bilateral wheezing. Labs were unremarkable. There was no pneumonia.

The patient was treated with intravenous (IV) Magnesium, Fluids, Steroids and bronchodilators. The patient responded to the treatment in the Emergency Department (ED). The patient remained clinically stable and was discharged home the next day on oral (PO) meds and bronchodilators.

This patient did not need acute inpatient hospitalization. She could have been placed in observation status while diagnostic testing and treatment were initiated. The observation period could be for up to 48 hours.

This patient improved rapidly after treatment in ED. She was discharged the next day after admission. This patient did not need acute inpatient hospitalization. She could have been discharged home on PO medications after a period under observation with close follow up as an outpatient.

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 hospital admission is not substantiated.