Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Chest Pain
Treatment: inpatient Stay
The health plan denied the requested inpatient stay as not medically necessary. The health plan's determination is upheld.

This man presented to the emergency department complaining of intermittent chest pain, dyspnea and orthopnea. His medical history was remarkable for coronary artery disease, coronary artery bypass graft surgery (CABG), percutaneous coronary intervention, aortic valve replacement, myocardial infarction, a left ventricular ejection fraction of 40% and cigarette smoking. The patient reported chronic dyspnea and had been using 3 liters/minute of supplemental oxygen at home since undergoing a CABG. His blood pressure was 115/77 millimeters of mercury (mmHg) with a heart rate of 79 beats/minute. His respiratory rate was 24/minute with a room air oxygen saturation of 96%. An electrocardiogram showed sinus rhythm without acute changes. His serum troponin and brain (or B-type) natriuretic peptide (BNP) levels were normal. A chest computed tomography (CT) angiography showed no evidence of pulmonary embolism. The patient was treated with intravenous Furosemide and was admitted to the hospital for evaluation of suspected acute coronary syndrome. A cardiac catheterization showed normal right and left ventricular filling pressures. Coronary angiography showed patent grafts and stents. The patient's previously prescribed Ticagrelor was discontinued, as this can cause dyspnea. Clopidogrel was prescribed. He was seen by a pulmonologist who opined that obstructive sleep apnea, obesity and possible chronic obstructive pulmonary disease (COPD) could be contributing to the patient's symptoms. Bronchodilators were recommended. The patient was discharged.
The medical necessity for an inpatient level of care is at issue.

I uphold, in whole, the determination that an inpatient level of care was not medically necessary.

No. Based on the documentation provided, an inpatient level of care was not medically necessary.
This patient, with a history of coronary artery disease, presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received for his chest pain did not require an inpatient admission and could have been provided under an alternate status. This approach has been shown to be both safe and cost-effective and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE)/Society for Academic Emergency Medicine (SAEM )/Society of Cardiovascular Computed Tomography (SCCT)/Society for Cardiovascular Magnetic Resonance (SCMR) Guidelines for the Evaluation and Diagnosis of Chest Pain and the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guidelines for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Upon presentation, the patient also complained of dyspnea. However, his oxygen saturation remained within normal limits on his usual amount of supplemental oxygen. His chest was clear on auscultation and a chest CT angiography showed no evidence of pulmonary emboli. Right and left heart filling pressures were normal. Thus, an inpatient admission was not medically necessary on the basis of this patient's dyspnea.