Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory/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) by emergency medical services (EMS) with a concern for chest pain, mild blurry vision, left arm and left face weakness and numbness. She has a past medical history that is notable for hypertension and hyperlipidemia. Vital signs at presentation were a body temperature of 36.7 degrees Celsius (C), blood pressure of 142/85 millimeters of mercury (mmHg), pulse of 93 beats/minute, respiratory rate of 18 breaths/minute, and oxygen saturation of 97%. The patient was reported to appear in no acute distress and was hemodynamically stable when she arrived at the ED and the initial physical exam was notable for normal heart sounds, right upper extremity sensation diminished, steady gait, no extremity edema, and clear lungs on auscultation.
The patient was evaluated by diagnostic studies which were notable for a computed tomography (CT) scan of the head which showed no hydrocephalus, no intracranial hemorrhage or acute finding of any kind.
An electrocardiogram (ECG) showed T wave inversions in leads V1-V6, a metabolic panel that showed no acute abnormalities and a complete blood count that showed no acute abnormalities. The patient was administered aspirin and subsequently admitted to the hospital for further evaluation of a suspected transient ischemic attack (TIA) evaluation and management. The patient was monitored with telemetry and scheduled neurologic assessments and she continued her home medications for hypertension and hyperlipidemia. She was evaluated by a chest x-ray that showed no evidence of acute cardiopulmonary disease, trans-thoracic echocardiography which showed no significant valvular heart, and a preserved ejection fraction and a carotid ultrasound which did not show any no significant stenosis. The patient was evaluated by a cardiology specialist and no invasive procedures were recommended and the patient remained hemodynamically stable and was discharged with a plan to follow up with cardiology in the outpatient setting. The patient remained hemodynamically stable until the time of discharge.
At issue is the medical necessity of an inpatient admission.
The requested health service/treatment of inpatient admission was not medically necessary for this patient.
The patient did not have altered mental status and was not suspected to have arteritis. She has a medical history that is notable for hypertension and hyperlipidemia and did not have persistent severe hypertension (systolic blood pressure (SBP) greater than 180 millimeters of mercury (mmHg) or diastolic blood pressure (DBP) greater than 110 mmHg). The patient's right sided neurologic symptoms were not severe or persistent and the chest pain was not severe and did not require treatment that could only be rendered at the inpatient level of care.
The diagnostic evaluation included diagnostic laboratory tests, a carotid ultrasound, trans-thoracic echocardiography, a chest x-ray and head CT scan all of which did not identify an acute abnormality. The ECG and cardiac monitoring did not identify any acute cardiac arrhythmias of immediate concern. The patient was evaluated by a cardiology consultant and recommended for outpatient follow up. The patient was not diagnosed with an acute stroke and had no findings on brain imaging that required an admission. She did not require an immediate inpatient procedure, parenteral anticoagulation, intravenous infusion of a platelet inhibitor, vasoactive medication, or antiarrhythmic medication. She did not have any medical conditions or receive any treatments or monitoring that required an inpatient admission. The patient could have safely and appropriately been rendered care at a lower level.
As such, the requested health service/treatment of inpatient admission was not medically necessary for this patient.