Appeal type: Medical necessity
Decision: Overturned

Cardiac/Circulatory Problems - Chest Pain
Inpatient Hospital

This is a case of a female, with a history of chronic chest pain, for about 1 year, who presented to the emergency department, with a complaint of chest pain and syncope episode while ambulating in a restaurant. The patient complained of some shortness of breath, and chest pain radiating to the back. At baseline, the patient takes aspirin, amlodipine, omeprazole, and Sinemet. The patient has a past medical history of Parkinson's disease. On arrival in the emergency department (ED), her temperature was 36.2 C, the heart rate was 74, respirations were 18, and the blood pressure was 121/74. Physical exam showed an awake and alert patient, in no acute distress. The cardiopulmonary exam showed equal breath sounds, regular rate, and rhythm, with no murmurs or gallops. Head computed tomography (CT) was done, which showed no acute abnormalities. Twelve-lead electrocardiogram (EKG) was done, which showed sinus bradycardia, with diffuse T wave abnormalities, possibly due to myocardial ischemia. White blood cell count was normal, hemoglobin normal, electrolytes and renal function were normal. Initial cardiac troponin was elevated at 0.142, normal D-dimer, pro brain natriuretic peptide (BNP) at 107, normal magnesium level and normal international normalized ratio (INR). Urinalysis showed no signs of infection. The patient's heart score was calculated at 6, and the patient was admitted to the hospital for an evaluation of acute coronary syndrome.
Given the EKG abnormalities, and the elevated troponin, the patient was started on a heparin infusion, and was taken to the cardiac catheterization lab, for an evaluation. Previous heart catheterization in 2016, showed nonobstructive disease, and mild luminal irregularities. Two dimensional (2D) echocardiogram was done, which showed a normal ejection fraction, no wall motion abnormalities, no evidence of left ventricular outflow obstruction. Subsequent troponin levels decreased down to 0.01. The left heart catheterization did not reveal obstructive disease but showed mild myocardial bridging in the mid left anterior descending (LAD). The heparin drip was discontinued, and the patient was started on medical management. The chest pain subsided, the patient no longer experienced shortness of breath following the heart catheterization. She was safely discharged to home, with close outpatient follow-up.

The health plan's determination is overturned.
Yes, the requested inpatient stay is medically necessary for this patient. Inpatient hospitalization is necessary for this type of presentation. The patient suffered a non-ST elevation myocardial infarction causing syncope, therefore inpatient admission is indicated.
The patient has clear documentation of non-ST elevation myocardial infarction, as evidenced by EKG changes in the form of T wave changes, positive troponin with a subsequent decrease after initiation of heparin infusion. As a result, inpatient hospitalization is indicated in this situation and is the standard of care per 2015 American College of Cardiology (ACC)/American Heart Association (AHA)/Society for Cardiovascular Angiography and Interventions (SCAI) guidelines for non-ST elevation myocardial infarction (NSTEMI).