Diagnosis: Human rhinovirus positive.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission. The denial is upheld.

Patient is an adult with a past medical history significant for anxiety, depression, and asthma, who presented to the emergency room with complaints of shortness of breath and cough.

Vitals on presentation included: Temperature 36.5 degrees C, Blood Pressure 153/96, Pulse 112, Respiratory Rate 16, oxygen (O2) saturation 97% (percent) on Room Air. Laboratory values were notable for the following: white blood cell count (WBC) 25.2, Hemoglobin (Hgb)-13.7, Hematocrit (Hct)-39.9, creatinine-0.86, glucose-114, procalcitonin-0.14. COVID test negative.

Patient was empirically started on intravenous fluids (IV), antibiotics (Rocephin and Zithromax), and nebulizers. Patient tested human rhinovirus positive. Chest x-ray (CXR) was negative. Computed tomography (CT) scan of the lungs showed trace ground glass opacity in the lungs, nonspecific, and no lung consolidation. Patient remained afebrile and hemodynamically stable. She requested discharged to continue outpatient management.

According to medical records, patient presented with upper respiratory illness-like symptoms and tested positive for rhinovirus viral infection. She was afebrile, hemodynamically stable. Laboratory results were unremarkable except elevated WBC, but patient had recently received a course of steroids by her primary clinician. Additionally, CXR was negative, and her oxygen saturation was stable. Rhinovirus is the etiologic agent of most common colds and is responsible for one-third to one-half of cases in adults annually. Symptoms are typically self-limiting; there is no indication for antibiotic therapy in the absence of evidence of secondary bacterial infections. Based on findings, patient met criteria for observation level of management.

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 acute inpatient admission is not substantiated.