Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain and Substance Abuse.
Treatment: Inpatient admission.
The insurer denied: Inpatient admission.
The denial is upheld.

The patient is an adult male. He was hospitalized for Chest Pain (CP) and Substance Abuse. He presented to the ED (emergency department) for evaluation of central exertional CP (chest pain). His past medical history includes medical noncompliance, frequent hospital admissions for CP (chest pain), including leaving AMA (against medical advice), known coronary artery disease (CAD), congestive heart failure (CHF) from ICM 
(ischemic cardiomyopathy) with ICD (implantable cardioverter defibrillator), CABG (coronary artery bypass graft) (LIMA-LAD [left internal mammary artery-left anterior descending], SVG-RCA [saphenous vein graft- right coronary artery]), restenosis and PCI (percutaneous coronary intervention) to distal LM (left main coronary artery), esophagitis, essential (primary) hypertension, gastritis, hyperlipidemia, poorly controlled diabetes and SAH/SDH (Subarachnoid Hemorrhage/ subdural hematoma).
The patient's vitals in the ED (emergency department) were stable: BP (blood pressure) 139/75, P (pulse) 98, T (temperature) 96.8 Fahrenheit, R (respiration rate) 16 and SpO2 (pulse oximetry) at 96% (percent). Labs showed troponin were elevated at 153, 148, and 176, BNP (brain natriuretic peptide) 97, elevated alcohol at 187.0 and Hb (hemoglobin) 11.4. Chest x-ray was negative for acute findings. EKG (electrocardiogram) revealed normal sinus rhythm, rate of 94. No acute changes were reported. The clinical impression and plan were ACS (acute coronary syndrome) ruled out, likely stable angina, Venofer iron infusions for IDA (iron deficiency anemia), mild alcohol withdrawal, low dose gabapentin for cravings and discharge with referrals for alcohol rehab, OP (outpatient) physical therapy with cane and OP (outpatient) PCP (primary care provider) and cardiology follow up. The requested coverage for inpatient admission was denied as not medically necessary. The denial is being appealed.

The inpatient admission was not medically necessary.

Based on the peer-reviewed medical literature, including the MCG (Milliman Care Guidelines) guidelines for Chest Pain, #(number) M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, positive troponin not explained by CKD (chronic kidney disease) and CHF (congestive heart failure), cardiac arrhythmia of immediate concern, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospital stay. The care that the patient received for chest pain like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the criteria attached MCG (Milliman Care Guidelines) Guideline 26th Edition: Optimal Recovery Guidelines, Chest pain ORG: (M-89) (ISC), this stay is not medically necessary for this patient.