Diagnosis: Rule out pneumonia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

Patient is an adult female who presented to the hospital with shortness of breath, wheezing and cough with productive green sputum for 4 days. At presentation vital signs were: Temperature 98.7 degrees F, respirations 20, Blood Pressure 157/94 and heart rate 98. Oxygen saturation was 94 % on room air. Patient was in no apparent distress and was speaking full sentences. Lung exam revealed bilateral wheezes. No edema was present, and the patient was alert and oriented to person, place and time. The white blood cell (WBC) count was 7,000, Hemoglobin 9.3, Electrolytes within normal limits, Potassium 3.2, Blood urea nitrogen (BUN)/ Creatinine (Cr) 11/0.8, B-Type Natriuretic Peptide (BNP) 49. Troponin was negative and venous blood gas (VBG) 7.43/35/56.
Chest X-ray (CXR) showed mild perihilar interstitial process consistent with volume overload/early congestive heart failure (CHF), rule out pneumonia.
The patient was treated with intravenous (IV) Steroids, Duo Nebs and Magnesium and was placed on Rocephin and Azithromycin for possible community acquired pneumonia (CAP). Patient was admitted to the hospital for Asthma Exacerbation and rule out CAP.

The patient responded to the treatment and was feeling better, in no distress, oxygen saturation was 100 % on room air. The patient was switched to oral antibiotics.

This patient did not need acute inpatient hospitalization and was stable after admission.
Unclear if she had pneumonia. She was speaking in full sentences, not hypoxic and was tolerating oral fluids. There was no clinical evidence of congestive heart failure (CHF). No edema, no jugular vein distention (JVD), and no rales on exam.

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 inpatient hospital admission is not substantiated.