Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest Pain.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

This is a patient with coronary artery disease.  She underwent coronary intervention of the right coronary artery (RCA) for angina.  She had repeated intervention.  Her chest pain started when she was sitting on the couch watching TV.  The pain improved after sublingual nitroglycerin.

The patient was brought to the emergency department (ED) with severe chest pain, which she described as squeezing, substernal pain, 10/10.  The pain was exacerbated by exertion and associated with an acute onset of shortness of breath.  She has a past medical history of hypertension (HTN), hyperlipidemia (HLD), multiple myeloma, obstructive sleep apnea (OSA), and hypothyroidism.

In the ED, her blood pressure (BP) was 191/93, heart rate (HR) was 70 beats per minute (BPM), and oxygen saturation (O2 sat) 99% on room air (RA).  Her physical exam revealed no significant abnormalities, but lower extremity (LE) edema.  Her white blood cell count (WBC) was low at 4.3, hemoglobin (Hb) 11.0, and potassium was 3.4 milliequivalents per liter (meq/L). Troponin was normal.

Her electrocardiogram (ECG) revealed normal sinus rhythm with left ventricular hypertrophy (LVH) and non-specific T wave abnormalities.  Her chest x-ray (CXR) was normal.  The patient received potassium, aspirin and oral nitroglycerin in the ED.  She was admitted to the hospital for further evaluation of chest pain.  Her BP normalized shortly after admission.  She was admitted to a telemetry bed.  She was treated with statins, beta blockers and antiplatelet agents.  She was consulted by cardiology and hematology/oncology consultation.

Her previous nuclear stress test prior to intervention revealed inferior ischemia.  Cardiology recommended an echocardiogram and nuclear stress test.  The patient underwent the echocardiogram.  It revealed normal systolic function of her left ventricle, ejection fraction (EF) 55-65%.  There were no regional wall motion abnormalities.  Doppler parameters were consistent with abnormal left ventricular relaxation.  
The patient underwent a stress nuclear test.  It revealed mild decreased perfusion noted in the inferior wall, extending into the inferoseptal segment and in the apex during stress images, which represent breast attenuation artifacts.  Gated single-photon emission computed tomography (SPECT) images demonstrated inferoseptal and apical hypokinesis and normal thickening.  The ejection fraction was calculated at 51% post stress and 48% post rest.  There was mild stress induced ischemia in the apex and inferior wall, extending into the inferoseptal after the pharmacological stress, moderate left and right ventricular dilatation, and apical and inferoseptal hypokinesis.  
The patient was recommended cardiac catheterization versus optimal medical management.  The patient opted for medical therapy.  Her medications were adjusted.  Her chest pain resolved.  Her serial troponin was normal.  Her repeated ECG did not reveal ischemic changes.

The hematology consult noted that the patient is under follow up of a hematologist / oncologist, and she is not on treatment.  It was recommended that she follow up with her hematologist / oncologist as an outpatient.  The patient was discharged from the hospital. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay medically necessary was not medically necessary for this patient.  The patient presented with a new onset of chest pain which reminded her symptoms of her previous episode of angina (questionable myocardial infarction (MI)).  Her BP was elevated.  However, there was no evidence of acute coronary syndrome (ACS).  Her troponin was normal.  Her electrocardiogram (ECG) did not reveal new dynamic ST/T changes.  Stress test revealed mild ischemia.  Based on the above, the patient did not suffer ACS, and inpatient admission was not medically necessary.  The patient's oral medications were adjusted.  That could have been accomplished at a lower level of care.  The patient presented with an elevated BP, but it normalized shortly after admission and remained stable.

The patient had a diagnosis of multiple myeloma and hematology / oncology was consulted.  That consult was not indicated in the hospital and could have been deferred.  There were no indications to provide inpatient level of care from her multiple myeloma standpoint.