Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.


The patient presented to the emergency department (ED) with abdominal bloating and chest pain. she developed these symptoms while waking up. Her chest pain was described like pressure like sensation. The pain was 3-4 and then resolved completely. The patient reported that she had similar symptoms in the past and underwent testing, but was not sure about results and how long ago it was.
The patient has a history of breast cancer, post left mastectomy, and chemotherapy. She did not undergo radiation.
Her blood pressure (BP) in the emergency department (ED) was 140/65, heart rate (HR) was 79 beats per minute (BPM) and oxygen saturation (O2 sat) was 99% (percent), and her temperature was normal. Her physical examination was unremarkable.
Her electrocardiogram (ECG) revealed normal sinus rhythm without acute ST-T changes. Her chest x-ray (CXR) was normal. Her lab results were unremarkable, including a negative troponin. The patient was admitted to the hospital for further evaluation of chest pain.
The patient was consulted by a cardiologist. He noted that the patient underwent coronary computed tomography angiography (CCTA) previously and the result was 0, but she has had no testing since that. The patient's condition was stable, her serial troponin was negative times 3.
The patient underwent a stress test which revealed "small-to-moderate size reversible defect in the inferior wall of the left ventricle consistent with ischemia; normal left ventricular wall motion and wall thickening; left ventricular ejection fraction calculated is 80% which is within the range of normal.
Cardiology follow up was done and noted that her chest pain resolved. Her stress test was low risk, she exercised for 9 minutes and achieved 100% maximum predicted heart rate (MPHR). Dual antiplatelet therapy (DAPT), Ranexa and Metoprolol for medical management were recommended and to consider cardiac catheterization as an outpatient. The patient was discharged home.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.
The patient presented with chest pain, which was recurrent by history. Her coronary risk profile was borderline. Her vital signs and physical examination were stable. Her ECG and cardiac enzymes were negative for ischemia.
The patient's stress test revealed a new defect in the inferior wall. However, the cardiologist felt that further work up, including cardiac catheterization, could have been accomplished at outpatient. The patient's condition and management did not achieve a level of inpatient admission. Care could have been provided at a lower level.
Per the first reference: "The goals in patients presenting to the ED or office with acute chest pain are: 1) identify life-threatening causes; 2) determine clinical stability; and 3) assess need for hospitalization versus safety of outpatient evaluation and management. These concerns entail consideration of the full extent of clinical data. The American College of Cardiology (ACC)/ American Heart Association (AHA) ST-Elevation Myocardial Infarction (STEMI) and Non-ST Elevation (NSTE) - acute coronary syndrome (ACS) guidelines categorize chest pain cause into 4 types: STEMI, NSTE-ACS, stable angina, and noncardiac. The 12-lead ECG, which should be acquired and interpreted within 10 minutes of arrival to a medical facility(Section 2.3.2, ECG), is pivotal in the evaluation because of its capacity to identify and triage patients with STEMI to urgent coronary reperfusion. Other ST-T abnormalities consistent with possible ischemia also mandate prompt evaluation in a hospital setting. In both cases, transfer should be by Emergency Medical Services (EMS); personal automobile for this purpose is associated with increased risk and should be avoided. Patients with stable angina or noncardiac chest pain that is not life-threatening should be managed as outpatients". 

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