Appeal type: Medical necessity
Decision: Upheld

The patient is a female with a history of hypertension and gastroesophageal reflux disease (GERD) who presented to the emergency room (ER) during the early morning hours with complaints of shortness of breath and chest pain. The patient reported several days to one week of shortness of breath, and one day of left-sided chest pain that radiated to the left arm. It was described in the reviewed documents as "lasting 5 minutes and went away on its own." In some notes, the chest pain was described as "exertional," but details on levels of exercise that were associated with the patient's chest pain were not seen in the reviewed notes. The pain was similar to pain that she experienced while abroad approximately 5 years ago. At that time, she was given supplemental oxygen and then sent home from the hospital.

The shortness of breath was described as a "sensation that she could not take a deep breath." Some authors also documented that the patient reported bilateral pain in the upper back and shoulders over the days preceding her ER visit. Initial vital signs were as follows: Temp. 97.8, blood pressure (BP) 177/89 millimeters of mercury (mmHg), respiratory rate (RR) 16, heart rate (HR) 70, and oxygen saturation 100% on room air. Physical exam revealed normal back exam, normal pulmonary exam with clear lung fields and non-labored breathing, normal cardiac exam, normal vascular exam, as well as normal neurologic exam. Electrocardiogram (EKG) at that time revealed normal sinus rhythm, rate of 73, inverted T wave in V1. (Of note, an inverted T wave in V1 has been noted in 5% of women on previous studies in the medical literature).
Labs at that time revealed: Troponin T less than (<) 6 (within normal range), white blood cell (WBC) count 7.98, hemoglobin/hematocrit 12.1/37.1, platelets 296, sodium (Na) 139, potassium (K) 3.7, chloride (Cl) 103, Bicarb 21, blood urea nitrogen (BUN) 26/creatinine (Cr) 0.70, glucose 105. A chest x-ray revealed no pleural effusions or pneumothorax and "clear lungs." The patient was treated with her home medicines of aspirin, atenolol, and ranitidine. No additional medications - such as additional anti-platelet therapy (such as Plavix or Brilinta), anti-coagulant (such as Lovenox or IV Heparin), angiotensin-converting enzyme (ACE) inhibitor/angiotensin II receptor blockers (ARB), nitroglycerin, or statin were given to the patient.

The health plan's determination is upheld.

The inpatient stay is not medically necessary for this patient.
Per chart review, the patient did not meet the following criteria for inpatient level of care. These criteria are the diagnoses of ST-Elevation Myocardial Infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), "ACS" with left bundle branch block, and significant EKG changes. Moreover, this patient was not treated with standard medical therapy for STEMI, NSTEMI, or ACS. Specifically, the patient did not receive anti-coagulation with intravenous (IV) Heparin or subcutaneous (SC) Lovenox, ACE inhibitor or ARB, nitroglycerin (NTG), statin, or a 2nd anti-platelet medication such as Plavix or Brilinta. Per the ACP Hospitalist review article, to support an inpatient admission with these diagnoses, "the patient must require the currently recommended management for serious, potentially life-threatening unstable angina or ACS. Anything less implies he or she could be managed in observation."
Per review of the patient's chart, the severity of her condition did not merit an inpatient hospitalization. Specifically, she had chest pain and shortness of breath, but she did not have documented evidence of STEMI, NSTEMI, significantly abnormal EKG, or significantly abnormal chest x-ray. Moreover, she was not treated with the standard medications - dual anti-platelet therapy, ACE inhibitor/ARB, statin, anticoagulants such as IV Heparin or SC Lovenox 1 milligram per kilogram (mg/kg) twice daily (bid) - that would likely be utilized to treat these more serious cardiac conditions. In addition, the intensity of services that were rendered - no IV drips needed, no urgent/emergent procedures needed - suggests that she did not require inpatient hospitalization. Lastly, her echocardiogram revealed normal left ventricular systolic function and no significant valvular abnormalities. Her nuclear stress test revealed "no evidence for MI or ischemia."
Therefore, an inpatient level of care was not medically necessary.