Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Inpatient level of care

The insurer denied coverage for inpatient level of care.

The denial is upheld.

This case involves an adult male who has a history of hypertension as well as end-stage renal disease and hemodialysis. The documentation indicated he was sent to the hospital by his hemodialysis center due to the complaints of chest pain. After finishing dialysis, he was also told his blood count was low. The physical examination revealed a normal rate and rhythm with no significant findings. It was recommended he undergo laboratory diagnostic studies. The documentation indicated an EKG (electrocardiogram) revealed a sinus rhythm with first-degree AV (atrioventricular) block which was also seen in a prior EKG. The chest x-ray revealed median sternotomy wires. His B-type natriuretic peptide (BNP) was 2276. The documentation indicated nephrology was consulted who recommended to admit the patient. The patient did have an elevated troponin and chronic anemia. His hemoglobin was 6.9. The patient was admitted and continued with treatment to include medication administration. The documentation does indicate his troponin was likely elevated due to end-stage renal disease (ESRD). They continued to trend troponin and EKGs to rule out acute coronary syndrome (ACS). The patient did have complaints of chest pain at the site of recent surgery. He was started on additional medication for hypertension. He did receive intravenous (IV) iron supplementation while hospitalized as well. The documentation detailed he did continue with treatment and was discharged due to a period of medical stability. It was recommended he be discharged with instruction to follow-up.

The Milliman Care Guidelines (MCG) were referenced for this review. Per these guidelines, inpatient admission was not indicated.

Specifically, the patient did not exhibit any of the following which are required for inpatient admission:

1)	Active massive hemorrhage
2)	Active hemolysis with rapidly progressive anemia
3)	Hemodynamic instability that is severe or persistent
4)	Active bleeding that cannot be rapidly controlled
5)	Cardiovascular symptoms (ie, dyspnea, chest pain, heart failure) that are severe or persistent
6)	Neurologic symptoms (ie, cognitive impairment, recurrent syncope or near syncope) that are severe or persistent
7)	Cardiac arrhythmias of immediate concern
8)	Acute peripheral ischemia (eg, pulseless, cool, mottled, or cyanotic extremity)
9)	High-risk low platelet count
10)	Acute renal failure
11)	Other significant finding or clinical condition judged not to be within scope of observation care
12)	Ongoing transfusion for blood loss (greater than 2 units)
13)	Continuous IV infusion of anticoagulation, platelet inhibitor, vasoactive, or antiarrhythmic medication
14)	IV fluid to replace significant ongoing (eg, for over 24 hours) losses 
15)	Pulmonary artery catheter monitoring
16)	Supplemental oxygen or respiratory treatments for over 24 hours that are performable only in acute inpatient setting
17)	Immediate inpatient surgery
18)	Other treatment or monitoring requiring inpatient admission.

Therefore, based on the MCG's, observation care appears appropriate for the care of this patient.

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

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