Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital 
The determination is upheld.

The patient has a past medical history significant for coronary artery disease, status post coronary artery bypass graft (CABG), hiatal hernia, fibromyalgia, gastroparesis, hypertrophic cardiomyopathy, and pelvic inflammatory disease who presented to the hospital with complaints of chest pain that had been going on for two-three weeks. The pain radiated to the right side of the abdomen.
The patient described the abdominal pain as steady and diffuse. At the same time, the chest pain was intermittent and occasionally occurred at rest and sometimes with movement. Reportedly, the patient was seen by her primary care physician (or provider) (PCP) and was given antibiotics for her gastrointestinal (GI) complaints. The patient denied shortness of breath, fever, chills, nausea, vomiting, diaphoresis, or any other symptoms.
The initial evaluation included an electrocardiogram (EKG), and the troponin did not demonstrate any evidence of acute coronary syndrome.
When seen by the admitting physician, the patient was afebrile. Her blood pressure was 148/92, respiratory rate 20 breaths/minute, and oxygen saturation 98% room air. The patient was awake and alert and in no acute distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft and non-tender. The neurological exam was unremarkable.
Laboratory evaluation revealed that serum sodium was 142, potassium 3.7, chloride 110, bicarbonate 30, blood urea nitrogen (BUN) 12, creatinine 0.92, and glucose 105. Liver function tests were within normal limits. The white blood cell count was 6.8, hemoglobin 12.7, hematocrit 39.2, and platelets 255.
The chest x-ray demonstrated no acute abnormalities. A computed tomography (CT) scan of the chest, abdomen, and pelvis showed no acute abnormalities.
The patient was admitted to the hospital with a diagnosis of lower back pain, lower abdominal pain, constipation, and chronic abdominal pain. The main reason for admission was to rule out acute coronary syndrome. The patient was continued on aspirin, beta-blocker, and statin. An abdominal ultrasound was ordered.
In the hospital, the patient was seen by a cardiologist who suggested that the patient had atypical chest pain. The patient was also seen by a GI specialist who recommended to advance diet as tolerated and to continue with the pain medication and bowel regimen. Stress management and an outpatient appointment with a psychiatrist were also recommended.
During the hospital stay, the patient was ruled out for acute coronary syndrome.
Since the patient's clinical condition improved and acute medical conditions were ruled out, the patient was transitioned to outpatient care.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient at the acute inpatient level of care.
The abdominal pain was most likely related to chronic constipation. Neither the results of the physical exam nor the laboratory studies or diagnostic tests pointed toward the presence of a serious medical problem necessitating admission at the acute inpatient level of care.
Based on the nationally accepted standards of care, admission at the acute inpatient level of care is required in cases of chest pain and hemodynamic instability, respiratory distress, chest pain, indicative of serious diagnosis other than coronary artery disease, also in cases of angina or myocardial infarction."

 A lower level of care was reasonable to rule out acute coronary syndrome and other medical conditions contributing to the abdominal pain. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care. The admission for observation was justified.

Based on nationally accepted standards of care, admission at the acute inpatient level of care is required in cases of chest pain and hemodynamic instability, respiratory distress, chest pain, indicative of serious diagnosis other than coronary artery disease, also in cases of angina or myocardial infarction. The review of the medical records demonstrated that the patient had none of the circumstances listed above. In this clinical case, the patient's chest pain was not associated with serious reasons requiring admission at the acute inpatient level of care. Furthermore, this patient was ruled out for acute coronary syndrome.