Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: inpatient hospital admission
The insurer denied inpatient hospital admission.
The health plan's determination is upheld.  

The patient is a male who presented to the emergency department (ED) after an episode of chest pain and leg cramping. He also reported intermittent palpitations. His medical history was remarkable for hypertension, hyperlipidemia, diabetes, paroxysmal atrial fibrillation, stroke, coronary artery disease, myocardial infarction, chronic kidney disease, catheter ablation for ventricular premature complexes and morbid obesity. In the ED his blood pressure was 170/84 millimeters of mercury (mmHg) with a heart rate of 101 beats/minute. His room air oxygen saturation was 99%. His physical exam was remarkable for obesity and lower extremity edema. An electrocardiogram showed sinus rhythm without acute changes.
His serum troponin level was normal and remained normal when re-measured. His serum creatinine level was 1.81 milligrams (mg)/deciliter (dl). A chest x-ray showed no acute pathology. The patient was admitted to the hospital. An echocardiogram showed normal left ventricular systolic function and grade 2 diastolic dysfunction. The next day, the patient denied chest pain but complained of brief episodes of palpitations. A Holter monitor was placed. His troponin level remained normal. His creatinine level was 1.71 mg/dl. He underwent rest/stress myocardial perfusion imaging. This showed a possible small area of ischemia in the apical anterior septum. The Holter monitor showed no arrhythmias. His creatinine level was 1.91 mg/dl. Isosorbide was prescribed and the patient was discharged.
At issue is the medical necessity of inpatient hospital admission.

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

The requested health service/treatment of inpatient hospital admission was not medically necessary for this patient.
Based on the documentation provided, an inpatient level of care was not medically necessary. This man, with known coronary artery disease, presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation of the patient until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care. This approach has been shown to be safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /The American College of Chest Physicians (CHEST)/Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT)/Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Therefore, the requested health service/treatment of inpatient hospital admission was not medically necessary.