Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient admission for medical necessity. 
The denial was upheld. 

The patient is a male with a past medical history significant for systemic lupus erythematosus (SLE), atrial fibrillation, hypertension, aortic valve replacement and ascending aortic aneurysm resection, left bundle branch block, pacemaker, chronic vertebral compression fractures, multi-substance abuse, and depression who presented to the hospital with complaints of substernal chest pain that was described as pressure-like, and non-pleuritic. It was associated with shortness of breath. The pain started two hours after the patient consumed crack cocaine in a suicide attempt. In addition, the patient drank one pint of vodka.
The laboratory evaluation revealed that his white blood cell count was 12.0, hemoglobin was 12.6, hematocrit was 37.5, and platelets were 178. His sodium was 138, potassium was 3.8, chloride was 106, bicarbonate was 21, blood urea nitrogen (BUN) was 12, creatinine was 0.97, and glucose was 92. The liver function tests were normal. The troponin was slightly elevated.
The patient was admitted to the hospital with a diagnosis of chest pain and elevated troponin in the setting of drug abuse. The admitting physician suggested that the elevated troponin was related to demand ischemia. Another clinical problem was suicidal ideations/attempts. Therefore, a psychiatry consultation was requested. According to the psychiatrist, the patient tried to commit suicide and regretted that the attempt was unsuccessful. The psychiatrist indicated that the patient needed a one to one (1:1) observation. It was reported that the patient was noncompliant with his psychiatric medications. 
The abdominal ultrasound revealed a complex 4.4 centimeter (cm) renal cyst with a solid mass-like component with fake separations. Therefore, a magnetic resonance imaging (MRI) of the abdomen was ordered, which the patient was unable to complete due to anxiety. For the treatment of dysphoric mood and active suicidal ideations, the patient was continued to be followed by a psychiatrist and was started on Abilify. The patient voluntarily wanted to be admitted to an inpatient psychiatric facility but subsequently, change his mind.
At the end of the hospitalization, the patient left the hospital against medical advice.
At issue is the medical necessity of the Inpatient stay.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Inpatient stay was not medically necessary for this patient.
The patient underwent a thorough workup that ruled out acute coronary syndrome. There was no evidence that the patient had hemodynamic instability or respiratory distress. There was no mention that the patient's chest pain was related to aortic dissection, pneumothorax, or aortic aneurysm. The chest pain was noncardiac in its origin and was not related to a serious medical condition requiring immediate attention. Other medical issues were stable, including chronic issues such as severe mitral valve regurgitation, and lupus. It was mentioned that the patient had a prolonged partial thromboplastin time (PTT), however, there was no evidence of bleeding. It was reported that the patient had a prolonged corrected QT interval (QTC) interval, but there was no evidence of arrhythmias of immediate concern.
The patient was evaluated by a psychiatrist who put him on a 1:1 observation for suicidal ideations, but the documentation did not state when these precautions were stopped. 
The severity of the patient's condition and the complexity of services provided did not justify the Inpatient stay.
Therefore, the health service of Inpatient stay was not medically necessary.