Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission 

The denial is upheld

This case involves an adult female with history of hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), uterine fibroids, and prediabetes who presented to the hospital with chest pain, palpitations, and shortness of breath that had been ongoing for 2 weeks. She had chest pain/burning on the left side with radiation to the jaw and left arm associated with numbness. Vital signs noted blood pressure 129/90, pulse of 134, respirations of 16, temperature 98.4 Fahrenheit, and oxygen saturation of 100% on room air. The patient endorsed intermittent palpitations that would last a few minutes at a time. There was associated nausea with chest pain for 1 day. On exam, she was tachycardic. She had normal heart sounds. Her pulmonary effort was normal. Her breath sounds were normal. The patient described her chest pain as pressure-like at the sternum with radiation into both upper extremities. Radiographs of the chest were unremarkable. Electrocardiogram (EKG) revealed sinus tachycardia with premature ventricular contraction (PVC). There were no ST elevations or depressions (finding on EKG). There were inverted T waves in lead III, V2, that was changed from prior (finding on EKG). Computed tomography (CT) of the chest noted no pulmonary emboli. There was nonspecific mild inflammatory small airway disease. The patient was admitted to telemetry for high-risk acute coronary syndrome. CT coronary angiogram noted normal findings. It was noted that the patient's chest pain was likely GERD. Coronary artery disease had been ruled out. There was a plan to continue multimodal therapy for GERD with outpatient gastrointestinal follow-up. She was then deemed stable for discharge.

Per the cited references, admission for chest pain is indicated when there is hemodynamic instability that is not readily corrected by appropriate treatment, when there is associated respiratory distress, when the chest pain is indicative of serious diagnosis other than coronary artery disease, or when there is severe pain that requires acute inpatient management. 

In this case, the patient presented to the hospital with complaints of chest pain, palpitations, and shortness of breath that have been ongoing for 2 weeks with symptoms concerning for high-risk chest pain/acute coronary syndrome. The patient had both potential cardiac issues and neurological issues which consisted of an episode of left-sided upper and lower extremity weakness and left-sided facial numbness that lasted for 15 to 30 minutes. However, the documentation did not support that the patient had hemodynamic instability that could not be addressed with appropriate treatment, associated respiratory distress, or chest pain that was indicative of serious diagnosis other than coronary artery disease. The documentation did not detail that the patient had severe pain that required acute inpatient management. The CT was negative for pulmonary emboli and didn't show calcification. Normal EKG and enzymes overnight would be adequate work-up for this patient with recommendations for outpatient follow-up. The patient's care could have been completed at a lower level. 

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.