Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department with complaints of left-sided chest pain as well as mild shortness of breath.
Reportedly, the patient was given nitroglycerin and aspirin while in the dialysis unit, and after taking these medications, the patient noted some decrease in the level of chest pain.
The chest pain radiated to the left arm. The patient described the pain as aching without aggravating or alleviating factors. She denied a fever, chills, cough, back pain, vomiting. The patient was able to tolerate oral intake.
Review of systems was obtained on admission and was positive for chest pain. All other systems were reviewed and negative.
On the physical exam that was performed by the admitting physician, the patient was afebrile, heart rate was 77 beats per minute (bpm), blood pressure 169/76, respiratory rate 18, and oxygen saturation 100% on room air. The patient was in no acute distress, was well-groomed, and well-developed. Her head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The patient's lungs were clear to auscultation and the cardiovascular exam was unremarkable. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that her white blood cell count was 7.97, hemoglobin 8.4, hematocrit 25.2, and platelets 174. Sodium was 138, potassium 3.9, chloride 100, bicarbonate 28, blood urea nitrogen (BUN) 23, creatinine 8.08, and glucose 110. Liver function tests were within normal limits.
An electrocardiogram (EKG) demonstrated normal sinus rhythm, 72 beats per minute (bpm), normal QRS complex, incomplete right bundle branch block, prolonged QT interval.
At the time of admission, the patient was diagnosed with chest pain. She was admitted to the telemetry unit, serial cardiac enzymes were ordered. The patient continued to receive aspirin and a beta-blocker.
The nephrology service was consulted since the patient had end-stage renal disease requiring hemodialysis. She patient was continued on her usual blood pressure medications. Her past medical records were requested in regard to the previous history of HIV infection.
During the hospital stay the patient was ruled out for acute coronary syndrome. She was seen by a cardiologist who indicated that the patient did not have an acute coronary event.
The patient refused all cardiac testing and interventions, including a stress test.
She was evaluated by a psychiatrist who did comment that the patient had the mental capacity to make her own decisions. This psychiatrist indicated that the patient had paranoid delusions that seemed to be chronic. The patient appeared to be at/to baseline and was able to meet her basic needs at the time of the evaluation. Her chest pain completely resolved and the patient was discharged from the hospital. The health plan's determination is upheld.
This patient presented to the hospital with complaints of chest pain. At the time of the initial evaluation, she was afebrile and hemodynamically stable. Her EKG was not completely normal but was not suggestive of an acute myocardial infarction.
A computed tomography (CT) angiogram of the chest did not reveal any significant abnormalities that would justify admission at an acute inpatient level of care. The patient was ruled out for acute coronary syndrome since the cardiac enzymes remained normal. She was seen by a cardiologist who suggested performing a stress test that the patient refused.
Overall, the patient remained in a stable clinical condition and reported a complete resolution of the chest pain within a short period of time. The patient was evaluated by a psychiatrist and was found to be at baseline. There was no need for inpatient psychiatric treatment. The patient's chronic kidney disease was stable, as well as her other medical conditions.
Taking into consideration all of the provider information, the patient did not require admission at the acute inpatient level of care. Care could have been provided at a lower level to rule out acute coronary syndrome. This kind of evaluation and treatment is usually performed at a lower level of care since, the patient had no other medical issues that would require admission at the acute inpatient level of care.