Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left foot pain, chest pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


This is a patient who presented to the emergency department (ED) with worsening of left foot and ankle pain. The patient had severe lower extremity (LE) arterial disease. The patient called his primary medical doctor (PMD) because of worsening pain and was advised to go to the emergency department (ED). The patient used to see a vascular surgery specialist, but this doctor was not on his provider list any more. The patient was complaining on worsening of left leg claudication, extreme pain in the left foot with numbness and tingling.
The patient also had chest pain. He described his chest pain as constant and he felt it for months. (Another note documented intermittent chest pain with exertion, and another note, by a cardiology consultant, mentioned sharp chest discomfort when laying on his left side. The cardiologist also noted that the patient did not have chest pain at presentation). He had an outpatient stress test and it revealed an infarct and ischemia in the apex and inferior wall with an ejection fraction (EF) of 40%.
The patient was supposed to have a cardiac catheterization at this hospital on the day of presentation, but the procedure was cancelled. (According to another note, prior authorization for the cardiac catheterization was pending). His left foot was cool and tender to the touch. The dorsalis pedis (DP) pulse was not palpable. There were no ulcerations and the sensation was intact. The white blood cell count (WBC) was 4.1, hemoglobin (Hb) was 12.7. pro brain (or B-type) natriuretic peptide (BNP) was 226. The troponin was negative. The rest of the lab results were normal.
His electrocardiogram (ECG) revealed sinus rhythm at 67 beats per minute (BPM), with left ventricular hypertrophy (LVH), and no changes in comparison to a prior electrocardiogram (ECG).
The patient was given pain medications, including intravenous (IV) morphine. The patient was admitted to the hospital. He was started on intravenous fluids (IVF), pain medications. The patient also continued on his home medications for hypertension (HTN) and hyperlipidemia.
A cardiology consultation was obtained. The patient's status was upgraded to inpatient. The patient underwent a cardiac catheterization. The cardiology recommendations were for  intense medical therapy and risk factors modification. His shortness of breath was treated with a nebulizer. His blood pressure (BP) was still elevated and was treated with oral medications. The patient still required pain medications, Oxycodone and Neurontin for leg pain.
A vascular surgery consult was obtained and recommended an angiogram of the lower extremity (LE).The patient was started on intravenous (IV) heparin for his LE ischemia. The patient was on IV heparin and oral medications waiting for the procedure, because it was a weekend. The patient underwent a lower extremity (LE) angiogram and his left popliteal artery was occluded. The patient underwent left superficial femoral artery (SFA) popliteal artery stent placement and balloon angioplasty. His DP was palpable at the end of the procedure.
The patient was started on Plavix and Aspirin. The heparin drip was discontinued. The patient required bed rest for 3 hours after the procedure. The patient suffered from severe pain in his legs. It was interpreted as reperfusion pain, because the foot appeared to be well perfused. He had palpable DP, posterior tibial (PT) and preserved motor function. The patient was reassured and discharged home.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. The patient presented with an ischemic leg. He had chronic pain due to peripheral vascular disease (PVD), the diagnosis was established previously, but his pain was getting worse. The patient was also mentioned to have a chest pain and abnormal stress test, but that was not a reason he went to the ED. He did not have chest pain when he was seen in the ED and later at the hospital. His troponin was normal and his electrocardiogram (ECG) did not have ischemic changes. His chest x-ray (CXR) did not reveal evidence of congestive heart failure (CHF) and his brain (or B-type) natriuretic peptide (BNP) was not high. The patient had a high risk for coronary artery disease (CAD), but from his chest pain prospective, he did not have indications to stay at the hospital as an inpatient. 
The patient's BP was elevated upon arrival, but it was normalized after his oral medications for BP control started. The patient had symptomatic leg ischemia. He required pain control medications and was treated with oral narcotics. He received a morphine injection in the ED, once. The patient's leg was ischemic, with DP not palpable, but there was no evidence of gangrene or non- healing ulcers. The patient underwent LE angiogram and intervention and the delay was due to the weekend. However, the patient did not need to stay over the weekend. His prolonged hospital stay was due to delay of care. It was not done for medical reasons, but for scheduling problems. He could have been discharged after 24 hours observation on oral pain medication and brought back for a LE angiogram and intervention on Monday. He had an ischemic foot, but no evidence of gangrene or ulcerations. There was no osteomyelitis. The patient was symptomatic with an ischemic foot, but he was stable to arrange the angiogram and intervention shortly after discharge from the hospital.
Per the third reference: "The goals in patients presenting to the ED or office with acute chest pain are: 1) identify life-threatening causes; 2) determine clinical stability; and 3) assess need for hospitalization versus safety of outpatient evaluation and management. These concerns entail consideration of the full extent of clinical data. The American College of Cardiology (ACC) / American Heart Association (AHA) ST-Elevation Myocardial Infarction (STEMI) and Non-ST-Segment Elevation Acute Coronary Syndrome (NSTE-ACS) guidelines categorize chest pain cause into 4 types: STEMI, NSTE-ACS, stable angina, and noncardiac. The 12-lead ECG, which should be acquired and interpreted within 10 minutes of arrival to a medical facility (Section 2.3.2, ECG), is pivotal in the evaluation because of its capacity to identify and triage patients with STEMI to urgent coronary reperfusion. Other ST-T abnormalities consistent with possible ischemia also mandate prompt evaluation in a hospital setting. In both cases, transfer should be by Emergency Medical Services (EMS); personal automobile for this purpose is associated with increased risk and should be avoided. Patients with stable angina or noncardiac chest pain that is not life-threatening should be managed as outpatients".