Appeal type: Medical necessity
Decision: Upheld

Chest Pain
Inpatient Hospital

The patient has a past medical history significant for hypertension, asthma, and uterine fibroids who came to the emergency department with complaints of left-sided chest pain that started one day before the day of admission. The patient stated that the pain became progressively worse, and at the time of admission, she rated the pain as 8/10 in severity. At the time of the initial evaluation, the patient described the pain as dull, aching. The pain was aggravated by movements of the left arm and upper chest. It was also aggravated by breathing and was associated with shortness of breath and dizziness. The patient denied similar symptoms in the past. A review of systems was negative for nausea, vomiting, abdominal pain, headache, palpitations. The electrocardiogram (EKG) demonstrated normal sinus rhythm, normal QRS complex, no evidence of acute ischemia. The chest x-ray showed no acute abnormalities. The patient was admitted to the hospital with the diagnosis of unspecified chest pain. Two additional sets of troponin, and an echocardiogram was ordered. Other clinical problems included hypertension, anemia, and asthma. These chronic medical problems were stable. During the hospital stay the patient was seen by a cardiologist who recommended telemetry monitoring, echocardiogram stress test, and anemia workup. The cardiologist also recommended the continuation of treatment for hypertension. The patient was also seen by a pulmonologist who recommended to rule out acute coronary syndrome, also a continuation of treatment with bronchodilators as needed for asthma that was a chronic medical problem. During the hospitalization, the patient underwent a stress test. It showed no evidence of ischemia. An echocardiogram was performed and showed normal left ventricular ejection fraction.
Even though the patient was anemic, there was no evidence of active bleeding. The patient received 1 dose of Venofer and subsequently oral iron supplements. The patient's anemia was attributed to heavy menses, therefore outpatient follow-up with a gynecologist was recommended. In the hospital, the patient remained in stable clinical condition and was discharged home. The health plan's determination of medical necessity is upheld in whole. The requested health service/treatment of inpatient hospital stay was not necessary in this clinical case since the patient remained in stable clinical condition throughout the entire hospitalization and did not require any interventions or diagnostic tests that would justify admission at the acute inpatient level of care. This patient presented to the hospital with complaints of chest pain that looked atypical and was associated with tenderness to palpation in the chest. At the time of the initial evaluation, the patient was afebrile and hemodynamically stable. The vital signs were not alarming. The physical exam was reassuring. As mentioned above, it revealed tenderness in the chest wall to palpation. Laboratory evaluation was nonrevealing. The patient had normal cardiac enzymes. The clinical significance of mildly elevated liver enzymes was unclear. The EKG did not show any changes consistent with acute ischemia or any other significant abnormalities that would contribute to the patient's symptoms. In the hospital, the patient was seen by a cardiologist and a pulmonologist, who recommended a number of diagnostic studies that included a stress test and an echo. Taking into consideration these facts, it is clear that upon presentation to the hospital and during the hospitalization the patient remained in a stable clinical condition, and the main purpose of the hospitalization was to rule out an acute coronary syndrome. Usually, this type of care is provided at a lower level. The patient had no unstable clinical conditions and did not require any interventions or diagnostic tests that would justify admission at the acute inpatient care.