Diagnosis: Asthma Exacerbation

Treatment: Acute Hospital Stay

The insurer denied the acute hospital stay. The denial was upheld.

This is a female patient with a history of asthma, uterine fibroids, anxiety and depression. She presented to the emergency Department (ED) with complaints of cough, wheezing, congestion and pleuritic chest pain. The patient reported that she ran out of her asthma medication. Bilateral expiratory wheeze was noted on physical exam. A chest x-ray was performed that was noted to be normal. A respiratory virus panel was performed that was positive for rhinovirus/ enterovirus. Laboratory work up was preformed that revealed white blood cell (WBC) count was 14.9K. The patient received nebulized bronchodilators and oral steroids with minimal response. The patient was admitted to the hospital for further treatment. She continued on Duonebs, Mucinex, oral Prednisone, and Doxycycline was added for bronchitis. Her symptoms improved and she was discharged home.

Based on the documentation in the chart, this patient did not need acute inpatient hospitalization. She was being treated orally. She was tolerating oral intake. The patient was in no acute distress. She was hemodynamically stable. She was not hypoxic. There was no evidence of pneumonia, pleural effusion or pneumothorax on chest x-ray.

The patient could have been discharged home on oral steroids and bronchodilators with close follow-up as an outpatient. The patient was admitted and discharged the next day. In the hospital, she was treated with oral steroids and bronchodilators. The patient could have been treated with the same in the outpatient setting without admission to the hospital. The prior denial is upheld.

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

The carrier's denial of coverage for the acute hospital stay is upheld. The medical necessity is not substantiated.