Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient presented to the emergency department complaining of one month of intermittent non-exertional, pleuritic, burning, right-sided chest pain and intermittent nausea. Her medical history was remarkable for hypertension, hyperlipidemia and diabetes. Her blood pressure was 146/92 millimeters of mercury (mmHg) with a heart rate of 80 beats/minute. Her respiratory rate was 18 breaths per minute with a room air oxygen saturation of 100% (percent). She was afebrile. Her physical exam was remarkable for right upper quadrant tenderness. An electrocardiogram showed sinus rhythm and was a normal tracing. The patient's serum troponin level was normal and remained normal when remeasured. A chest x-ray showed no acute pathology. A right upper quadrant ultrasound showed hepatic steatosis. There was no evidence of cholelithiasis or acute cholecystitis. The patient's liver function tests were mildly abnormal. Her D-dimer level was normal. She was treated with aspirin, famotidine and Maalox and admitted to the hospital.
On the admission physical exam, there was right costochondral tenderness, right upper quadrant tenderness and a positive Murphy's sign. The patient was evaluated by a cardiologist who noted lower extremity edema, worse on the left than the right, and opined that her symptoms were likely noncardiac in nature. A lower extremity venous studies, an echocardiogram and a cardiac stress test were recommended. The venous studies were performed and showed no evidence of deep vein thrombosis. The patient denied chest pain and left the hospital against medical advice.
The medical necessity for an inpatient admission is under review.

Based on the documentation provided an inpatient level of care was not medically necessary.
This patient, with multiple cardiac risk factors, presented with atypical symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers, and a normal electrocardiogram. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received for her chest pain did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with current guidelines, including the 2021 American Heart Association/American College of Cardiology/American Society of Echocardiography, American College of Chest Physicians/ Society for Academic Emergency Medicine /Society of Cardiovascular Computed Society for Cardiovascular Magnetic Resonance (AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
There was also some concern that the patient's symptoms might be due to a gastrointestinal condition. However, right upper quadrant ultrasound showed no evidence of gallbladder disease and there was no evidence of acute intra-abdominal infection or gastrointestinal bleeding. There is no documentation that the patient was unable to tolerate oral hydration and meals. The records provided do not document an indication for inpatient admission on the basis of this patient's abdominal pain.

The health plan's determination is upheld.