Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Inpatient Hospital

This is a patient with a past medical history significant for hypertension and diabetes mellitus who presented to the emergency department with complaints of left-sided chest pain that started one day before the day of admission. The pain was intermittent. Each episode lasted for approximately 20 minutes. The pain was mild to moderate intensity and radiated to the left arm and back and was associated with dizziness. The patient also had mild shortness of breath but denied diaphoresis, palpitations, or symptoms of upper respiratory infection.
Vital signs were: temperature 98 degrees Fahrenheit (F), blood pressure 155/104, heart rate 94/minute, respiratory rate 19, and oxygen saturation 100% on room air (RA).
On the physical exam, the patient was in no acute distress. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The neck was supple, with no jugular vein distention (JVD). Lungs were clear to auscultation. The heart exam was within normal limits. The abdominal exam was unremarkable. Laboratory evaluation revealed that the white blood cell count was 5.86, hemoglobin 11.5, hematocrit 36.1, and platelets 242. Sodium was 140, potassium 3.3, chloride 105, bicarbonate (HCO3) 28, blood urea nitrogen (BUN) 10, creatinine 0.81, and glucose 86. Liver function tests were within normal limits. The troponin was normal.
A chest x-ray demonstrated no significant abnormalities. An electrocardiogram (EKG) demonstrated normal sinus rhythm, premature atrial contractions (PACs).
The health plan's determination is upheld. The inpatient stay was not medically necessary. The physical exam, laboratory studies, and diagnostic tests did not reveal the presence of a serious medical condition that would justify admission at the acute inpatient level of care.
The patient was admitted to the hospital with a diagnosis of chest pain and shortness of breath, hypertension, diabetes mellitus. Serial troponins were ordered. A cardiology consultation was requested. In the hospital, the patient was seen by a cardiologist who recommended performing a stress test to rule out ischemia and also to obtain an echocardiogram. A nuclear stress test was performed and was interpreted as a normal study.
The echocardiogram demonstrated normal left ventricular ejection fraction, no significant valvular abnormalities. During the hospital stay, the patient remained in satisfactory clinical condition and was discharged home.
Considering the patient's risk factors as well as complaints at the time of admission, work up was indicated. At the same time, this patient was afebrile, hemodynamically stable, had unremarkable results on the physical exam as well as laboratory studies and diagnostic tests. Even though the patient complained of subjective dyspnea, there were no clinical signs that the patient had acute respiratory issues considering the normal respiratory rate, oxygen saturation. The patient's lungs were clear to auscultation.
Finally, the workup performed in the hospital did not reveal any evidence of serious medical conditions that would justify admission at the acute inpatient level of care.
Taking into consideration all of this information, admission at the acute inpatient level of care was not medically necessary. Care could have been provided at a lower level.