Appeal type: Medical necessity
Decision: Upheld

Chest Pain
Inpatient Hospital

The patient is a female with a past medical history significant for gastroesophageal reflux disease (GERD) and uterine fibroids who presented to the emergency department with complaints of chest pain and abdominal pain, which radiated to the back.
At the time of the initial evaluation, the patient denied nausea, vomiting, diarrhea. The pain was intermittent.
The review of systems was negative for fever, chills, dysuria. At the time of the initial evaluation, the patient was afebrile, blood pressure was 157/99, heart rate 72 beats per minute (bpm), respiratory rate 18/minute, and oxygen saturation 97% on room air. She appeared to be comfortable, in no acute distress, oriented to person, place, time, situation. The cardiac exam was unremarkable. The patient had epigastric tenderness with no guarding or rebound. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that sodium was 145, potassium 3.3, chloride 120, bicarbonate 19, blood urea nitrogen (BUN) 11, creatinine 0.42, glucose 58. Liver function tests were within normal limits. Troponin, lactic acid were within normal limits.
On initial evaluation, the patient was found to have hypocalcemia. Her calcium was measured at 5.1. Subsequently, the calcium level was rechecked and came back normal.
White blood cell count was 6.98, hemoglobin 16.4, hematocrit 45.9, platelets 242.
Computed tomography (CT) angiogram of the abdomen and pelvis was negative for aortic aneurysm or dissection.
The patient had two hyperdense lesions within the right hepatic lobe, which were too small to characterize. Therefore, a magnetic resonance imaging (MRI) was recommended. The patient also had a right adrenal nodule.
CT angiogram of the chest was negative for aortic aneurysm or dissection.
Electrocardiogram (EKG) demonstrated normal sinus rhythm, normal PR interval, there was no evidence of acute ischemia.
The patient was admitted to the hospital for further evaluation of the abdominal and chest pain, hypocalcemia. The patient's clinical condition improved, her symptoms were attributed to possible GERD, therefore she was recommended to take Prilosec twice a day instead of once a day. The patient was discharged home with the recommendation to follow up on the abnormalities diagnosed on the CT scan.
The patient was recommended to follow-up with a gastroenterologist and possibly have esophagogastroduodenoscopy (EGD) performed as an outpatient because of a long-standing history of GERD.

The health plan's determination is upheld.

This patient presented to the hospital with complaints of atypical chest pain and epigastric abdominal pain. In the appeal letter from the hospital, there was a reference to Milliman Care Guidelines (MCG) 23rd edition criteria for abdominal pain. It was stated that the admission was justified in this case because the patient's abdominal pain was associated with severe electrolyte abnormalities, which in this case defined as hypocalcemia. Apparently, the repeat laboratory evaluation demonstrated that the patient's hypocalcemia was not accurate, and it was simply a laboratory error.
In general, the results of the physical exam, laboratory studies, and diagnostic tests did not point to the presence of acute medical problems necessitating admission at the acute inpatient level of care. The patient had some abnormalities noticed on the CT angiogram of the chest, abdomen, and pelvis, but those changes were not acute, unlikely related to the patient's symptoms, and did not require further evaluation in the hospital.
Taking into consideration all these facts, it was clear that neither the severity of the patient's condition nor the complexity of the services provided justified admission at the inpatient level of care.
There were no clear indications for admission at the acute inpatient level of care considering the patient's stable condition, and lack of significant abnormalities on the physical exam, laboratory studies, and diagnostic tests. The hypocalcemia, which was initially mentioned, was a laboratory error.