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 (ED) complaining of 3 days of right-sided chest and right arm pain that started after doing some pull-ups. Her medical history was remarkable for hypertension, hyperlipidemia, diabetes and obesity. One year prior she had a cardiac catheterization which she reported was abnormal; no coronary interventions were performed at that time. In the ED, her blood pressure was 166/86 millimeters of mercury (mmHg) with a heart rate of 86 beats/minute. Her room air oxygen saturation was 98% (percent). An electrocardiogram showed sinus rhythm with possible left ventricular hypertrophy; there were no acute changes. A chest x-ray showed no acute pathology. Her serum troponin level was normal. The patient was admitted to the hospital to rule out acute coronary syndrome. Her troponin levels remained normal. An echocardiogram showed normal left ventricular size and systolic function. There was trace to mild aortic regurgitation and mild mitral regurgitation. Myocardial perfusion imaging showed moderate anterior ischemia and evidence of an apical infarction. The left ventricular ejection fraction was 46%. Cardiac catheterization was recommended; however, the patient left the hospital against medical advice. The medical necessity of an inpatient admission is under review.

Based on the documentation provided, an inpatient level of care was not medically necessary.
This patient, with cardiac risk factors of hypertension, diabetes and hyperlipidemia, 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 no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. Based on her HEART [History, Electrocardiography, Age, Risk factors, Troponin] score, she was at low risk for major adverse cardiac events. 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 (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes. The documentation provided does not justify a five day hospital stay. Based on the records provided, it does not appear as if there was a medical reason for the delay in performing the myocardial perfusion imaging. The study could have been performed once the patient's troponin level was confirmed to be normal. Then, if the patient agreed, the cardiac catheterization could have been performed the following day, with discharge when stable provided the procedure was uncomplicated.