Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

This male patient was hospitalized for chest pain. He presented to the hospital emergency department (ED) for evaluation of chest burning and vomiting a small "clot" of blood, in the setting of recent pharyngitis being treated with Tylenol and amoxicillin. His past medical history was unremarkable. 

The patient's vital signs were stable. His throat was red. The patient's electrocardiogram (EKG) was normal and the monitor showed sinus rhythm (SR) / sinus tachycardia (ST). The patient's treatment included a gastrointestinal (GI) cocktail, proton pump inhibitor (PPI) and admission for trending of troponin for presumptive viral myocarditis. Troponin returned elevated at 3.210 followed by 3.218 and 1.544.  The patient's chest x-ray was normal. His chest computed tomography angiogram (CTA) was negative for pulmonary embolism (PE). 

The patient's diet was tolerated and he was discharged to home with outpatient (OP) cardiology follow up. This is an appeal of the denied claim that the requested acute inpatient hospital stay was medically necessary for this patient which was approved at the observation level of care.

No, the proposed inpatient hospital admission was not medically necessary.
Based on the peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. 

Per the Milliman Care Guidelines (MCG) for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, acute myocardial infarct (AMI), chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, sepsis, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. The care the patient received, including management of presumed, uncomplicated viral myopericarditis like in this case, is routinely provided safely and effectively at a lower level of care, such as, at the Observation level of care. In this particular case, there was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period. 

Therefore, the proposed treatment was not medically necessary, based on the submitted information and the current published medical literature.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
In this particular case, there was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period. The care the patient received, including management of presumed, uncomplicated viral myopericarditis like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, the proposed treatment was not medically necessary, based on the submitted information and the current published medical literature.