Diagnosis: exacerbation of asthma, shortness of breath, wheezing
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a female with hypertension (HTN), diabetes mellitus (DM), and asthma. The patient had a prior pulmonary embolism (PE), Parkinson's, and anxiety. The patient had a hospital admission a month prior but had no prior intubations. She presented with dyspnea, wheezing, coughing, and malaise after exposure to COVID.

In the emergency department (ED), the patient's temperature was 36.8 degrees Celsius, blood pressure (BP) was 138/76, heart rate (HR) was 88 beats per minute (bpm), respiratory rate (RR) was 16, and her peripheral capillary oxygen saturation (SpO2) was 93 percent (%) on room air (RA). She was in no distress, her heart was regular, she was breathing comfortably with wheezing, she had leg edema, and she was alert and oriented. The patient's white blood cell count (WBC) was 7.4, sodium (Na) was 136, bicarbonate was 25, blood urea nitrogen (BUN) was 10, and creatinine was 0.98. The Influenza, respiratory syncytial virus (RSV), and COVID tests were all negative. Her chest x-ray (CXR) was clear. A computed tomography pulmonary angiogram (CTPA) showed no pulmonary embolism (PE), pneumonia, or edema. She was diagnosed with an asthma exacerbation and was started on steroids and nebulized bronchodilators. The next day, she had improved with scattered wheezing. Treatments continued. The following day, she was feeling better, her lungs were clear, and she was continued on prednisone and nebulizers. The next day, she was doing well and was discharged on a course of prednisone.

At issue is the medical necessity for an inpatient hospital admission.
I uphold the health plan's determination, in whole.

An inpatient admission was not medically necessary.
The patient presented with dyspnea and wheezing with no other diagnoses. She was not severely ill, and she had no organ dysfunction, respiratory distress, or gas exchange abnormality. She was improving over an ED course of care and improved significantly over a short time frame. She had no history of prior intubation and had not failed outpatient treatment. Given all of this, I do not think she needed an inpatient admission, as she did not require inpatient only testing, monitoring, or treatment and did not need an inpatient admission for prolonged or poorly responsive symptoms. I think an alternate level of care would have been reasonable, but I do not think an inpatient admission was needed.