Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated Troponin/Rule Out Acute Coronary Syndrome
Treatment: Inpatient Hospital Stay
The insurer denied an Inpatient Hospital Stay.
The determination is upheld.

This patient with a past medical history significant for asthma was brought to the emergency department after he was found unresponsive at home. Apparently, the patient had consumed alcohol. It was reported that at home he had pinpoint pupils. Emergency Medical Services (EMS) gave him Narcan, and afterward, the patient became alert.
Upon initial evaluation in the emergency department, the patient's blood pressure was 128/72, heart rate 114, respiratory rate 21 breaths/minute, and oxygen saturation 100% on room air.
In the emergency department, the patient underwent a computed tomography (CT) scan of the head, which revealed no acute hemorrhage, infarction, or mass effect. The urine drug screen came back negative. The patient was altered but awakened to voice, and followed commands.
The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. He was disoriented on the exam.
Laboratory evaluation revealed that the serum alcohol level was 256.7. The white blood cell count was 6.9, hemoglobin 13.0, hematocrit 39.3, and platelets 157. The sodium was 138, potassium 3.3, chloride 97, bicarbonate 25, blood urea nitrogen (BUN) 10.2, creatinine 0.89, glucose 120. The alanine aminotransferase (ALT) was 44, aspartate aminotransferase (AST) 61, and the alkaline phosphatase and bilirubin were normal. The brain (or B-type) natriuretic peptide (BNP) was less than 10. Troponin was 0.07. Lipase was 41.
The patient was admitted to the hospital with an elevated troponin to rule out acute coronary syndrome. It was mentioned in the history and physical (H&P) note that the patient denied chest pain. Serial troponins were ordered as well as an echocardiogram. The secondary diagnosis was alcohol abuse, hyperkalemia, and QT prolongation based on the electrocardiogram (EKG). According to the medical records, the acute coronary syndrome was ruled out.
Due to the history of alcoholism, the patient was monitored for alcohol withdrawal symptoms. He received a tapering dose of Ativan. The initial plan was to discharge the patient to a rehabilitation facility, however, at the end of the hospitalization, he requested to be discharged home. It was also mentioned that during the hospital stay, QT interval prolongation resolved. The patient was ruled out for venous thromboembolism. His D-dimer was elevated, however, a lower extremity venous Doppler was negative for deep vein thrombosis (DVT), and a computed tomography (CT) angiogram of the chest was negative for a pulmonary embolism. Since the patient's clinical condition improved, he was transitioned to outpatient care.
At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The patient presented to the hospital with several medical problems including altered mental status, which was most likely related to alcohol intoxication. The altered mental status improved very quickly. There was no evidence that the patient had severe alcohol withdrawal symptoms. His Clinical Institute Withdrawal Assessment (CIWA) score was low.
There was no evidence that the patient had significant electrolyte abnormalities that required frequent laboratory monitoring and replacement. Even though he was tachycardic initially, his heart rate came down after 2-3 days of hospitalization.
Even though it was reported that the patient had some nausea, there was no mention that he did not tolerate oral intake. There were no reports of increased perspiration, tremors, or other physical symptoms that would persist after the observation period.
The patient had mild rhabdomyolysis, which did not cause any acute kidney failure and likely was the culprit of elevated troponin levels. The patient's mild alcohol withdrawal was not associated with seizures. There were no reports that the patient had other significant medical history or any clinical conditions that would be aggravated by possible alcohol withdrawal.
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care to ensure that the patient did not develop severe alcohol withdrawal symptoms, rule out acute coronary syndrome, ensure resolution of rhabdomyolysis, and make sure that the patient's mild nausea did not interfere with adequate oral intake. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.  Inpatient level of care was not medically necessary.