Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient hospital admission

The insurer denied the inpatient hospital admission. 

The denial has been upheld.

The proposed inpatient hospital admission was not medically necessary.

This female patient with a submitted diagnosis of chest pain was hospitalized. She presented to the emergency department (ED) for evaluation of severe chest pain. Her blood pressure was elevated to 211/103. Her electrocardiogram (EKG) revealed sinus bradycardia, rate 57, and nonspecific T-wave changes in the lateral leads. Treatment included Tylenol, lidocaine patch, intravenous normal saline, intravenous hydralazine, oral amlodipine and resumption of oral metoprolol. Head computed tomography angiogram (CTA) reported mild to moderate narrowing of the right vertebral artery. Transthoracic echocardiogram (TTE) reported left ventricular hypertrophy (LVH) with left ventricular (LV) cavity obliteration. Coronary computed tomography angiogram (CTA) was negative for coronary artery disease (CAD). The patient's hypertension was under control and she was discharged home with outpatient follow-up with her primary care physician (PCP) and cardiology. The requested coverage for inpatient hospitalization was denied and the patient is appealing the decision.

Based on the current peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. 

Per the Milliman Care Guidelines (MCG) guidelines for Chest Pain, #M-89 and Hypertension # M-197, 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, pneumonia, hypertension requiring inpatient hospitalization, including hypertensive emergency
with evidence of acute and progressing target organ disease, such as, hypertensive encephalopathy/altered mental status or cerebral infarction or intracranial hemorrhage or myocardial ischemia or infarction or heart failure with pulmonary edema, aortic dissection, increased creatinine (new) with reduction of more than 50 percent in estimated glomerular filtration rate from baseline, papilledema, retinal hemorrhage, microangiopathic hemolytic anemia, seizure, adrenergic or sympathomimetic crisis, such as severe hypertension due to pheochromocytoma crisis, cocaine, phencyclidine, or amphetamine intoxication or clonidine withdrawal or any other medical condition, symptom or finding for which inpatient hospitalization was indicated.

In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient stay. The care the patient received, including all her testing and treatments like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment is not medically necessary.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.

In this particular case, there was no clinical decline or  an adequate response to treatment which required inpatient stay. The care the patient received, including all her testing and treatments like in this case, is routinely provided safely and effectively at a lower level of care.