Diagnosis: Asthma.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient has a history of mild intermittent asthma and presented to the emergency department (ED) with a three-day history of shortness of breath, wheezing, chest tightness, and some productive cough with yellow sputum. The patient took nebulizer treatments at home but did not improve. In the ED, the patient's vital signs were Temperature 99° Fahrenheit (F), blood pressure (BP) 150/88, pulse 121, respiratory rate (RR), and oxygen saturation 93% on room air (RA). The patient's peak expiratory flow (PEF) was 120. A lung exam revealed bilateral wheezing. A cardiovascular exam revealed tachycardia. The patient was alert and oriented x 3.

The patient was treated with steroids, bronchodilators, and magnesium. The patient improved with treatment in the ED. The patient's PEF improved to 375. The patient was admitted to the hospital for an asthma exacerbation. Vital signs per the history and physical were Temperature 98.4°F, pulse 101, RR 18, BP 140/80, and oxygen saturation 98% on room air. The patient was in no acute distress. The patient had scattered wheezing but was speaking in full sentences. The patient was still alert and oriented x 3. A venous blood gas (VBG) showed a pH of 7.44, bicarbonate of 35, and carbon dioxide level of 45. Electrolytes were within normal limits. A chest x-ray (CXR) revealed no infiltrates, effusions, or pneumothorax. The next day, the patient was switched to oral steroids. The patient was continued on bronchodilators, inhaled corticosteroid (ICS)/long-acting beta-agonists (LABA), and Singulair and was discharged home.

This patient did not need acute inpatient hospitalization. The patient could have been placed in observation status which could be for up to 48 hours. During this time, diagnostic testing and treatment could have been initiated. The patient improved rapidly. The patient was stable to be discharged home on oral medications after a period of observation. The patient remained afebrile and hemodynamically stable throughout, and was not hypoxic, with oxygen saturation 93-98% on room air. The patient was speaking in full sentences and tolerating oral intake. The patient's PEF had improved to 375 after treatments in the ED. The patient was discharged after one.

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.