Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The determination is upheld. 

This is a female patient who presented to the emergency department with left-sided chest pain that began one hour prior to arrival. The pain radiated from the left side of her chest to her left arm. She reported missing her doses of lisinopril and metformin for the past two days. The patient resided in a shelter and had a syncopal episode with a loss of consciousness while in the bathroom at the shelter, as reported by the staff there. There were no seizure-like activities, and she had no residual weakness. The patient had a significant family history of cardiac disease, with her mother, father, and brother experiencing myocardial infarctions at a young age. She had no other complaints.
Upon physical examination, the patient appeared well-groomed and was not in apparent distress. The cardiovascular examination revealed a regular heart rate and rhythm, normal heart sounds, no murmurs, no jugular venous distention, and no peripheral edema. 
The patient was admitted to the hospital with a diagnosis of chest pain, syncope, and diabetes mellitus. Upon evaluation by the admitting physician, the patient was free of chest pain. During her hospital stay, her clinical condition improved, including the resolution of chest pain. Additional workup, including an echocardiogram, revealed a normal ejection fraction and acute coronary syndrome was ruled out. The syncopal episode was considered vasovagal in nature. The patient was eventually transitioned to outpatient care, but her discharge was delayed due to difficulties with paperwork and logistical issues. At issue is the medical necessity of an inpatient stay. 

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. 
There were no clear indications for admission at the acute inpatient level of care for evaluation of syncope since there were no signs of hemodynamic instability or severe or persistent altered mental status. The imaging studies did not reveal evidence of an acute stroke, brain mass, or hydrocephalus. 
There was no indication that the syncopal episode was related to a pulmonary embolism, arterial dissection, acute congestive heart failure (CHF) exacerbation, acute blood loss anemia, or acute coronary syndrome. There were no indications for an immediate electrophysiological study or other interventions such as automatic implantable cardioverter defibrillator (AICD) placement. 
Based on the telemetry monitoring, there was no evidence that the patient had a high degree of atrioventricular block, bradycardia with sinus pauses, or bursts of supraventricular tachycardia. There was no evidence that the patient was severely dehydrated. The chest pain was not associated with hemodynamic instability or respiratory distress. It was reproducible, unlikely musculoskeletal in its origin. There was no clinical evidence that the patient had angina or myocardial infarction. The chest pain was not indicative of a serious diagnosis other than coronary artery disease.
The review of the medical records revealed that the patient remained in stable clinical condition during the entire hospital stay, and did not require any treatment or testing that would justify admission at the acute inpatient level of care.