Diagnosis: shortness of breath and wheezing
Treatment: inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient is an adult male with history of asthma, hypertension, obstructive sleep apnea (OSA). The patient was on Continuous Positive Airway Pressure (CPAP) at home. He presented to the emergency department (ED) with complaints of shortness of breath and wheezing.

The patient had taken his albuterol at home without relief.

On presentation: Blood Pressure was 154/87 mmHg, Respiratory Rate 26 breaths per minute, Heart Rate 105 beats per minute and oxygen saturation was 92 percent on room air.

The patient was noted to have some decreased air entry on lung exam with bilateral wheezing.

The patient was treated with Duo Nebs and Oral Prednisone in the emergency department and subsequently admitted for Asthma Exacerbation.

The patient was alert and oriented times 3 and was in no apparent distress. After treatment in the emergency department: Temperature was 97.1 degrees Fahrenheit, Heart Rate 80 beats per minute, Respiratory Rate 17 breaths per minute and oxygen saturation was 98 percent on room air. Peak Expiratory Flow (PEF) was in 300's, lung exam mild wheezing with no use of accessory muscles.

White Blood Cell (WBC) count was 5.2K, hemoglobin 12.4.
Chest X-ray showed no acute infiltrates or effusion or pneumothorax. Computed tomography (CT) was negative for Pulmonary Embolism. Initial Venous Blood Gases (VBG) were 7.32/72/41 and repeat was 7.36/62/82.

The patient was continued on treatment with Oral Prednisone and Duo Nebs.

After treatment, the patient reported feeling better and that his exacerbation had been caused by his running out of meds. Lungs were clear, CVS S1 S2 (heart sounds) were normal. The patient continued on Albuterol and Ipratropium Nebs and oral Prednisone.

This patient did not need acute inpatient hospitalization. He could have been placed in observation status while diagnostic testing and treatment were initiated. He had known asthma and obstructive sleep apnea (OSA). Lungs only mild wheeze which cleared up by the next day. He was tolerating oral food and fluids. Lab results were normal and he had no pneumonia or pathology. Venous Blood Gas (VBG) revealed mild compensated Respiratory Acidosis on the repeat VBG.

The patient improved after treatment in emergency department.

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 admission is not substantiated.