Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment:  Inpatient Hospital. The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient presented to the emergency department (ED)with dull pain in her neck that radiated to the left arm with paresthesia of her left fingers. The pain was 7/10, constant, getting worse, improved with nonsteroidal anti-inflammatory drugs (NSAIDs) on and off, and precipitated by carrying heavy weight. The pain started two weeks prior and worsened the morning prior to presentation. The patient also noted severe chest pain. It started the day before presentation. It felt like pressure, and it was 8/10 in severity, radiating from to the left arm, exacerbated by changing the position of left hand and the pain was more severe laying down. The pain was associated with nausea.
The patient had a history of coronary artery disease, post percutaneous coronary intervention (PCI) of the left anterior descending (LAD), prediabetes, hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD) and obesity. The patient tried to treat her chest pain with a muscle relaxant and failed. She was seen in the emergency department (ED) previously.
In the ED, her vital signs were normal. Her physical examination was normal. Her white blood cell count (WBC) was low at 3.8 and creatine kinase (CK) was 215. Her electrocardiogram (ECG) was normal. Her chest x-ray (CXR) was normal. In ED, the patient received aspirin and nitroglycerin and morphine.
She was admitted to the hospital to the telemetry unit for evaluation and management of her chest pain. A cardiology consultation was obtained.
The patient underwent an echocardiogram and it revealed a mildly reduced ejection fraction (EF) (45%). There were no wall motion abnormalities; normal diastolic function; normal right ventricle (RV) function. The patient ruled out for a myocardial infarction (MI) with three negative troponins.
She underwent a stress nuclear perfusion test which was normal. Her exercise capacity was normal. She did not have chest pain with stress. Her myocardial perfusion images revealed normal wall motion with calculated EF 69%. She was discharged home. At issue is the medical necessity of an inpatient admission.
The requested health service/treatment of inpatient stay was not medically necessary for this patient. The patient presented with atypical chest pain. Some of the features of her chest pain suggested musculoskeletal etiology, such as changing with position. Her neck pain also was suggestive of a musculoskeletal issue, possible cervical radiculopathy. However, a patient might have two types of pain at the same time, and might have unstable angina at the same time as radiculopathy. The patient had history of coronary artery disease (CAD) and recent coronary intervention and she had several coronary risk factors. It was appropriate to place the patient on telemetry for further evaluation. However, the patient's work up for CAD was negative. Her vital signs and physical examination were normal. Her ECG and cardiac enzymes were normal. Her stress nuclear scan was normal. The patient's condition and her work up did not meet inpatient admission criteria. She should have been managed at a lower level of care.