Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a male who presented to the ED with complaint of chest pain and shortness of breath. He has a past medical history which includes asthma, chronic obstructive pulmonary disease, liver cancer, hepatitis and hypertension. His initial vital signs include temperature 98.1, heart rate 95, respirations 21, blood pressure 121/81, and oxygen saturation 94%. At the time of this initial evaluation his pain intensity was listed as 7/10. His review of systems was negative except for what has been mentioned above. On physical exam no abnormalities were described. The patient describes his chest pain as starting three days ago and worse in the morning. He describes the pain as sharp, located in the mid chest, radiating to the left side, constant and worse when lying down. It was associated with shortness of breath and a nonproductive cough. 

The physician's impression was that the patient had chest pain secondary to bone metastasis. The patient was receiving morphine and the plan was to obtain a palliative care consult for further pain management. A pain assessment was completed. The pain was located in the patient's chest it was listed as 10/10 in intensity and described as aching. It was aggravated by physical activity and relieved by medications. The patient's hospital course stated that the patient was admitted to a general medical floor with the impression of chest pain secondary to metastatic disease. His pain improved with restart of pain medications and the patient exhibited no signs of possible cardiac cause of his chest pain. The patient was to be discharged with close follow-up with hematology and oncology. At the time of discharge he was referred to the liver and hepatitis clinic with follow-up appointment scheduled.

This patient presented to the ED with complaints of chest pain and shortness of breath that had started three days previously. The pain was described as pleuritic. The patient was known to have hepatocellular cancer with metastatic disease to his bones. The Troponin level x2 was within normal limits and his EKG did not show any ST segment changes. Certainly, if this patient had new ischemic changes, the electrocardiogram (EKG) and/or troponins would have been abnormal after three days of symptoms.

The literature cited shows that this patient would have been an appropriate candidate for an Observation unit; as he had no troponin elevations and no changes of injury on his EKG's that were consistent with acute myocardial injury or ischemia. Even with acute coronary syndrome ruled out, an Observation unit would have been appropriate for this patient since other necessary studies such as CTA of the chest to rule out pulmonary embolism and localizing the source of pain from metastatic disease could be accomplished in an Observation unit. The literature is clear that acute hospital admission for this type patient is not medically necessary and that this patient was an ideal candidate for an Observation unit. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.