Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for hypertension, chronic obstructive pulmonary disease (COPD), latent syphilis, human immunodeficiency virus (HIV), hepatitis C, polysubstance abuse, and schizoaffective disorder who presented to the emergency department with complaints of chest pain that started on the day of admission.  The pain started while the patient was eating breakfast and became progressively worse.  The patient described the pain as stabbing and located all over the chest.
In the emergency department, the patient received appropriate treatment for his condition that led to a complete resolution of the chest pain.  At the time of the initial evaluation, the patient also complained of hearing voices.  The patient reported that the voices told him that they were going to kill him.  At the same time, the patient denied any suicidal or homicidal ideations.
A review of systems obtained on admission was negative for fever, chills, night sweats, headache, visual changes, vertigo, abdominal pain, nausea, vomiting, diarrhea, or urinary retention.  On the physical exam, the patient was afebrile, his blood pressure was 103/76, his pulse rate was 73, he had a respiratory rate of 18, and an oxygen saturation of 98% on room air.  His head, eyes, ears, neck, throat (HEENT) exam was within normal limits.  The patient's lungs were clear to auscultation, the cardiovascular exam was unremarkable, the abdomen was benign, and the neurological exam was unremarkable.
The laboratory evaluation revealed that the patient's white blood cell count was 9.5, he had a hemoglobin of 13.7, a hematocrit of 40.4, and the platelets were 265.  He also had a sodium of 135, a potassium of 4.6, a chloride of 107, a bicarbonate of 22, a blood urea nitrogen (BUN) of 14, and a creatinine of 0.83.  His troponin was normal.
During the hospital stay, the patient was seen by cardiology, and it was determined that the patient's chest pain was secondary to amphetamine abuse.  The patient was admitted to the telemetry floor to rule out acute coronary syndrome.  His electrocardiogram (EKG) did not demonstrate any findings suggestive of an acute coronary syndrome, and his serial troponins remained negative.
The patient was also seen by a psychiatrist for an evaluation of his auditory hallucinations.  It was determined that the patient did not require an admission to inpatient psychiatric management.
Throughout the hospitalization, the patient remained in stable clinical condition and was discharged with a recommendation to follow with his primary care physician and a psychiatrist as an outpatient. 
The health plan's determination is upheld.
The requested health service/treatment of inpatient hospital stay was not medically necessary at the acute inpatient level of care considering the patient had no medical condition that would require an admission at the acute inpatient level of care.  The patient had an unremarkable physical exam, and the diagnostic studies and laboratory tests did not point towards a serious medical problem that would justify an admission at the acute inpatient level of care.
The patient had no signs of acute coronary syndrome based on the EKG and the normal serial troponin results.  There was no evidence that the patient had cardiac arrhythmias of immediate concern.  There was no evidence of congestive heart failure or any other emergency such as an aortic dissection.  Even though the patient had auditory hallucinations, there was no evidence of suicidal or homicidal ideations, and the patient did not require an admission to the inpatient psychiatric unit.
Taking into consideration all of this information, neither the severity of the patient's condition nor the complexity of the services provided justified an admission at the acute inpatient level of care.  The care could have been provided at a lower level.