Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems-Chest Pain
Treatment: Inpatient hospital stay

The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This is a case of a patient admitted to the hospital for the diagnosis of chest pain and rhabdomyolysis. The patient presented with a chief complaint of chest pain. Symptoms started intermittently two months prior to admission. Vital signs demonstrated temperature 98.4 degrees Fahrenheit, pulse 101, respiratory rate 20, blood pressure 132/82 and oxygen saturation 96% on room air. Physical exam showed no apparent distress or altered mental status. The patient was admitted to rule out acute coronary syndrome with serial troponin. The creatine phosphokinase (CPK) was 1200 on admission and he was treated with intravenous fluids. An electrocardiogram (EKG) showed no acute ST/T wave changes. The patient was recommended to have cardiology evaluation and echocardiogram. Echocardiogram showed normal wall motion and preserved ejection fraction. The patient was then discharged  with outpatient follow-up.

Medical necessity of an inpatient admission has not been established.
According to the documentation submitted the patient was admitted to rule out acute coronary syndrome. There was no hemodynamic instability, respiratory distress, aortic dissection, pneumothorax, cardiac tamponade, mediastinitis, pulmonary embolism, hypoxia, ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction or unstable angina. He also required short treatment with intravenous fluids for rhabdomyolysis but was able to be discharged in a timely fashion. Although the patient had needs best addressed in the hospital setting the monitoring, diagnostic workup and therapeutic interventions prescribed could have been safely administered at a lower level of care. Therefore, medical necessity of admission has not been established.

According to Up to date, 2020:
"Any patient with hemodynamic instability or significant respiratory distress is admitted to the intensive care unit (ICU). Patients with acute aortic dissection, pneumothorax, cardiac tamponade, and mediastinitis require admission and appropriate consultation.
Patients with pulmonary emboli with hemodynamic instability or significant hypoxia are admitted to the ICU. Stable patients with pulmonary embolism do not require admission to an ICU or telemetry monitoring. Some low-risk patients may even be treated as an outpatient.
Patients with ST-Elevation Myocardial Infarction (STEMI) receive reperfusion therapy via fibrinolytics or percutaneous coronary intervention and are admitted to the ICU. Patients at high risk for acute coronary syndrome (ACS) or death are admitted to an ICU; patients at moderate risk are admitted to a non-ICU monitored setting.
Patients not at low risk for ACS, but without known coronary artery disease or obvious signs of myocardial infarction, and without a clear alternative diagnosis, should be observed further, and myocardial ischemia ruled out using serial cardiac biomarkers, electrocardiogram testing, and possibly further testing. Patients at low risk with normal ECGs are managed in a non-ICU monitored setting, floor bed, or a chest pain observation unit, unless high-sensitivity troponin testing identifies them as safe for discharge. Exercise treadmill or pharmacological testing with or without nuclear imaging, as well as stress echocardiography and computed tomography coronary angiography, can assist cardiovascular risk stratification in the emergency department. Patients with an uneventful observation period, negative serial cardiac markers, and a normal stress test can be safely discharged with a referral for follow-up. If released without provocative testing, low-risk patients should have clear follow-up arranged, ideally within a few days of discharge. Follow-up within 72 hours is safe."