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 has a history of multiple myeloma, benign prostatic hypertrophy, and Vitamin D deficiency and presented to the emergency room (ER) with complaints of 1 month of atypical chest pain and fatigue. A stress test just prior to this date was interpreted as abnormal (the details of this test were not documented in the notes available for this review), and the patient's cardiologist called the patient to recommend that he report to the emergency department.
Per the chart review, the patient was clinically stable in the emergency room with vital signs within normal range. No significant lab, electrocardiogram (EKG), or physical exam abnormalities were documented. A cardiology consult was obtained. The patient was admitted to the hospital for a left heart catheterization. An echocardiogram was completed and revealed normal left ventricular ejection fraction of 60% with no significant valvular abnormalities. A coronary angiogram was performed and this revealed moderate left anterior descending (LAD) stenosis, minimal right coronary artery (RCA) stenosis, and distal left circumflex occlusion. A percutaneous coronary intervention (PCI) of the distal left circumflex was attempted, but failed due to inability of the wire to cross this lesion. The patient stayed one more day in the hospital and was discharged home. At issue is the medical necessity of an inpatient stay.

Although this patient had a one month history of intermittent chest pain and an abnormality on a recent stress test, the patient was asymptomatic on the date of hospital admission. No fever, tachycardia, tachypnea, or hypotension was noted. Additionally, no significant physical exam, lab, or EKG abnormalities were documented that might necessitate a hospital admission. Specifically, there was no documented evidence of altered mental status, bradycardia, tachycardia, tachypnea, significant arrhythmia, hemodynamic instability, hypotension, hypoxemia, respiratory distress, orthostasis, and/or decreased urine output. Without these abnormalities, hospitalization is not supported (1). With no reports of current chest pain or other significant symptoms on the date of admission and no significant abnormalities detected on lab and EKG review on that same day, this patient did not meet criteria for inpatient hospital admission. An echocardiogram revealed normal LV systolic function with a left ventricular ejection fraction (LVEF) of 60% and no significant valvular abnormalities.
Moreover, the patient did not undergo a coronary angiogram - the procedure that the patient was admitted so that he could undergo in a timely fashion - until day 3 of the hospitalization for unknown reasons.
Per chart review, the coronary angiogram seemed appropriate since this patient had a recent abnormal stress test (2). Inpatient status is not addressed in the 2014 guideline listed (2). The patient was reported to be asymptomatic and hemodynamically stable on the date of ER evaluation. In addition, the results of the stress test were referred to as abnormal, but the specific abnormalities were not documented. It is unknown if the test results were consistent with high risk, intermediate risk, or low risk features.
Lastly, a PCI was attempted but was unsuccessful. The patient was stable during and after the procedure. Despite this documented stability, the patient remained hospitalized.