Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute coronary syndrome.

Treatment: Inpatient hospital services

The insurer denied coverage for inpatient hospital services. The denial was upheld.

This patient is a female with history of asthma, morbid obesity, diabetes mellitus (DM), coronary artery disease (CAD) status post stents, hypertension (HTN), hyperlipidemia (HLD) and gastroesophageal reflux disease (GERD) who presented to the Emergency Department (ED) with complaint of chest pain and shortness of breath (SOB) since earlier that morning. As per the patient her chest pain was triggered by a fight between her two sons. The chest pain was central and pulsating, intermittent and non-radiating and different from the chest pains that she had when she had acute coronary syndrome (ACS). The patient denied fever or chills. The patient took her nebulizer but did not get relief so came to ED. Her vital signs at presentation were blood pressure (BP) 135/67, heart rate (HR) 101, respiratory rate (RR) 20, temperature (T) 98.2F., and oxygen (O2) saturations 96 % on room air.  The patient was in no acute distress (NAD). She was speaking in short sentences. The lung examination revealed bilateral wheeze. No respiratory distress is noted. The patient was awake and alert x 3 spheres.  The cardiac exam was unremarkable. The patient's symptoms were thought to be atypical for acute coronary syndrome.

The patient was treated with DuoNeb, steroids and Montelukast. The patient was still noted to be wheezing after treatment, so she was admitted inpatient. As per History & Physical Temperature:  98F., Heart Rate 111, blood pressure 132/84, respiratory rate 18 and o2 saturations 100% on room air. The patient was well appearing and in no acute distress. There was some decreased air flow noted at bases.  No rhonchi or wheezes were heard. The cardiovascular system (S1 S2) was normal. The patient was alert and oriented x3. The neurological exam was unremarkable. White blood cell (WBC) count was 9.7K. The myocardial infarction (MI) had been ruled out by serial Troponins and electrocardiogram. The chest x-ray showed no acute pathology.  The EKG showed normal sinus rhythm. There were no ischemic changes. The venous blood gas was PH- 7.38/PCO2- 41/ PO2- 41.

As per a progress note from a specified date, the patient was feeling better. She denied shortness of breath. There were no signs of infection noted.  Scattered rhonchi are noted in progress notes.  The Peak expiratory flow (PEF) was 200. The patient was seen by pulmonary service specialist.  It was recommended to switch to oral steroids. The possibility for myocardial infarction (MI) had been ruled out.

It appears that this patient did not need acute hospitalization. She could have been placed under Observation status while diagnostic testing and treatment were initiated. It appears that by a specified date the patient had improved. The patient was afebrile and hemodynamically stable. No signs of infection are noted. The chest x-ray did not reveal any acute pathology. The patient was tolerating fluids and food orally.

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

The carrier's denial of coverage for the inpatient hospital services is upheld. The medical necessity is not substantiated.