Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Hospital Admission

The insurer denied coverage for hospital admission

The denial is upheld 

The patient is a female with a history of pulmonary emboli, asthma, factor V deficiency, gastric ulcers, kidney stones, cholecystectomy, and novel coronavirus infection.  She was discharged from the hospital a few days prior related to evaluation and treatment for headaches.  She also had a history of allergic reactions to contrast dye, but tolerated several computed tomography angiograms in the past.  Home medications included Fioricet, dabigatran, diphenhydramine, Compazine, famotidine, gabapentin, and vitamin D.  She presented to the emergency department with sharp mid-sternal chest pain similar to the discomfort she experienced when pulmonary emboli were diagnosed and related that recently she had not taken two doses of dabigatran due to scheduled tooth extraction.  Initial vital signs in the emergency department included blood pressure blood pressure 105/69, heart rate 100, respiratory rate 22, temperature 97.8 Fahrenheit, and oxygen saturation on room air 98 percent.  Electrocardiogram revealed normal sinus rhythm and was normal, as was a chest X-ray.  Laboratory test results included white blood cell count 10.73, hemoglobin 13.4, creatinine 0.847, thyroid-stimulating hormone 1.34, and troponin<0.015, with subsequent troponin levels at 01:30 and 07:45 also <0.015.  She was pre-medicated for computed tomography angiography with diphenhydramine, famotidine, and methylprednisolone and underwent computed tomography angiography of the chest, which was normal, but after the test she developed hives and chest tightness and was treated with epinephrine, diphenhydramine, hydroxyzine, and another dose of methylprednisolone.  Vital signs later included blood pressure 105/56, heart rate 101 and oxygen saturation on room air 95 percent.  A few hours later she was described as improved, in no distress, with blood pressure 105/56, heart rate 101, and oxygen saturation 95 percent.  Later, she complained of continued chest pain and dizziness with standing, with upright heart rate 120, supine heart rate 115, blood pressure 113/56, and oxygen saturation 98 percent.  She ate breakfast and was treated with Percocet for chest pain.  Echocardiography revealed hyperdynamic left ventricular systolic function, normal right ventricular size and function and no evidence for pulmonary hypertension.  She was discharged to home on her home medications for outpatient follow-up.

There is no evidence that this patient required an inpatient level of care to evaluate her chest discomfort and to determine that her symptoms were not related to acute pulmonary embolism or acute coronary syndrome.  In addition, her allergic reaction to contrast dye responded promptly to treatment and she remained hemodynamically stable during this episode.  Evaluation and treatment should have been completed in the emergency department or at an observation level of care.  

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

The insurer's denial of coverage for the hospital admission is upheld. Medical Necessity is not substantiated.