Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest Pain.
Treatment:  Acute inpatient admission.

The insurer is denied coverage for acute inpatient admission.  The denial is upheld.

This is a female patient with a medical history of hypertension, familial hypercholesterolemia, coronary artery disease, status post coronary artery bypass graft (CABG), status post multiple percutaneous coronary interventions with stents, stroke, peripheral vascular disease, anemia, asthma, diabetes mellitus, depression/anxiety, chronic lumbago, and chronic, unrelenting chest pain syndrome with repeated visits to the hospital for chest pain.  She presented to emergency room with complaints of mid-sternal chest pain, worse than her baseline, and similar to prior times she'd been evaluated.  She also complained of constipation, lower back pain, and diffuse abdominal pain.  The patient's vital signs were: blood pressure 190/97, pulse 71, respirations 18, temperature 98.5F, and blood oxygen level 97%.  A triage note states the patient has taken 12-13 nitroglycerin tablets today.  Troponin was negative upon arrival.  An electrocardiogram (EKG) showed sinus rhythm with incomplete right bundle branch block.  A chest X-ray showed mild cardiomegaly and tortuous atherosclerotic aorta.  An abdominal X-ray showed a nonspecific non-obstructive bowel gas pattern.  She was given Lasix and multiple doses of intravenous (IV) Morphine.  The patient was admitted to telemetry for further evaluation and management of chest pain.  She was seen by Cardiology, who noted there was no evidence of acute coronary syndrome (ACS).  Cardiac biomarkers remained negative.  The consult notes the patient's symptoms are likely secondary to hypertensive response to severe back pain.  An echocardiogram showed normal left ventricular size and wall motion, severe tricuspid valve regurgitation, mild to moderate pulmonic valve regurgitation, and severe pulmonary hypertension.  Her medications were adjusted, her symptoms improved, and she was discharged.

The health care plan acted reasonably, with sound medical judgment and in the best interest of the patient.  The acute inpatient admission was not medically necessary.

The patient presented with a history of repeat evaluations for chest pain with a known history of coronary artery disease, bypass surgery, numerous stent procedures, and high nitroglycerin use.  The initial evaluation in the Emergency Room (ER) was unremarkable, including a nondiagnostic EKG and negative cardiac biomarkers.  There were no other high-risk symptoms suggestive of acute coronary syndrome, rather that of stable symptomatology.  As medically essential as it was to evaluate the patient's symptoms, inpatient admission was not medically necessary in this instance.  The patient's care could have been provided under the observational setting, allowing for additional diagnostic testing, which was done here.  There were no high-risk or concerning findings on diagnostic testing to necessitate further inpatient evaluation.  During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care.  Observational would have been appropriate.

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.