Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department (ED) with chest pain. The patient was brought by Emergency Medical Services (EMS). He patient reported chest pain that started one day prior to presentation. The patient described his chest pain as sharp and achy and it reminded him chest pain which previously required percutaneous coronary intervention (PCI).
The patient had a history of coronary artery disease (CAD), hypertension (HTN), cirrhosis and alcohol abuse. The patient suffered ST-Elevation Myocardial Infarction (STEMI) and underwent PCI of his circumflex (Cx).
The patient was recently admitted to another hospital and he was diagnosed with a gastrointestinal (GI) bleed. It resulted in severe anemia. His hemoglobin (Hb) was 4.2 at that time and he was transfused 2 units of red blood cells (RBCs). An endoscopy was done during the previous admission and the esophagogastroduodenoscopy (EGD) revealed small esophageal varices and small gastric varices. There was no more bleeding and the patient was discharged.
In the emergency department (ED), his BP was 134/85, heart rate was 103, blood pressure (BP), and respiratory rate was 16 per minute and the temperature was normal. The oxygen (O2) saturation was 97% on room air. The patient appeared to be in discomfort. He was non ill appearing, and not toxic appearing.
The patient had a rash on his chest, which was felt not to be due to shingles. In the ED it was described as different from shingles. His abdominal examination was unremarkable.
He had a tremor possibly due to alcohol withdrawal. His electrocardiogram (ECG) revealed sinus tachycardia and no evidence of acute ischemic changes. His troponin came back 0.181 nanograms/milliliter (ng/ml).
His bilirubin was elevated to 6.3 milligrams per deciliter (mg/dl). His aspartate aminotransferase (AST) was 136. His platelets were 28,000. Because of a concern of potential ethyl alcohol (ETOH) withdrawal, the patient was treated with benzodiazepines. The patient was admitted to the medical service for management of his chest pain and abnormal labs.
The admitting physician felt that the patient was dehydrated with hyponatremia. The plan was to treated with intravenous fluids (IVF) and antiviral treatment.
His rash subsequently was diagnosed as shingles. The patient was treated for his shingles with acyclovir and prednisone. The patient underwent an ultrasound of the abdomen and computed tomography (CT) scan of the abdomen and pelvis. It revealed hepatic steatosis.
The patient was evaluated by hematology for diffuse bruising due to thrombocytopenia. There was a lip hematoma found. The patient underwent the transfusion of one pack of platelets. His platelets improved to 104 thousand (K). The patient was placed on an alcohol withdrawal protocol. His serial troponin was going down 0.169- 0.131- 0.112. The patient's condition improved and his pain resolved.
The patient was discharged home. He was discharged on valacyclovir, thiamine, propranolol, lactulose and folic acid. An inpatient level of care is under review for medical necessity.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.
The patient presented with chest pain, a history of coronary artery disease (CAD) and a minimally elevated troponin. However, his chest pain was due to shingles-Herpes Zoster infection. His chest pain was not cardiac. He was treated with antiviral agents and steroids. The patient's condition was stable, his Herpes Zoster infection was not complicated. The management of his neuropathic pain due to Herpes Zoster did not require inpatient stay.
The patient had a long-standing history of alcoholic liver disease, which was not new. His liver disease was in chronic state, without complications and could have been managed as outpatient.
The patient had a history of ethyl alcohol (ETOH) abuse, but he did not demonstrate withdrawal symptoms.
The patient had thrombocytopenia, but he did not have evidence of major bleeding. His thrombocytopenia could have been handled at a lower level of care.
Per the first reference:  "The goals in patients presenting to the ED or office with acute chest pain are: 1) identify life-threatening causes; 2) determine clinical stability; and 3) assess need for hospitalization versus safety of outpatient evaluation and management. These concerns entail consideration of the full extent of clinical data. The American College of Cardiology (ACC)/ American Heart Association (AHA) ST-Elevation Myocardial Infarction (STEMI) and Non-ST Segment Elevation Acute Coronary Syndromes (NSTE-ACS) guidelines categorize chest pain cause into 4 types: STEMI, NSTE-ACS, stable angina, and noncardiac. The 12-lead electrocardiogram (ECG), which should be acquired and interpreted within 10 minutes of arrival to a medical facility (Section 2.3.2, ECG), is pivotal in the evaluation because of its capacity to identify and triage patients with STEMI to urgent coronary reperfusion. Other ST-T abnormalities consistent with possible ischemia also mandate prompt evaluation in a hospital setting. In both cases, transfer should be by EMS; personal automobile for this purpose is associated with increased risk and should be avoided. Patients with stable angina or noncardiac chest pain that is not life-threatening should be managed as outpatients".