Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart Attack
Treatment: Inpatient Hospital Stay
The health plan denied: Inpatient Hospital Stay
The determination is: Upheld

The patient is a male with a past medical history significant for hypertension, schizophrenia, heart failure with preserved ejection fraction, cocaine use, and non-ST elevation myocardial infarction (NSTEMI) who presented to the hospital with shortness of breath and intermittent substernal chest pain that he described as a squeezing sensation. The chest pain was worsened by exertion and relieved by some posture. The pain radiated to the left arm. The patient endorsed cocaine use the night before his presentation. The patient denied fever, chills, diaphoresis, headache, palpitations, wheezing, or abdominal pain.
The initial electrocardiogram (EKG) that was performed in the emergency department was remarkable for T-wave inversions in lead 4 - 6. The patient had an elevated creatine phosphokinase (CPK) but normal troponin. The patient was admitted to the hospital with chest pain secondary to cocaine use.
When seen by the admitting physician the patient looked comfortable and in no acute distress. By that time, the chest pain resolved, and the patient denied shortness of breath. On the physical exam, the patient was afebrile. His blood pressure was 116/74 millimeters of mercury (mmHg), with a respiratory rate of 17/minute, and an oxygen saturation of 97% on room air.
Cardiac monitoring was implemented, and the regimen of home medications was restarted. It was reported that the patient's blood pressure was within normal range.
In the hospital, the patient was seen by the substance abuse team. It was mentioned that previously the patient was enrolled in the substance use disorder (SUD) rehabilitation program. They recommended returning to existing treatment after discharge.
At issue is the medical necessity of the inpatient stay.
The health plan's determination of medical necessity is upheld in whole.
The inpatient hospital stay was not medically necessary for this patient.
Cocaine use is a well-established risk factor for the development of chest pain and acute coronary syndromes such as myocardial infarction. Therefore, patients presenting with chest pain and a recent history of cocaine use require careful evaluation to determine the need for admission to the acute inpatient level of care.
Several factors should be considered when determining the need for admission, including the presence of high-risk features on electrocardiogram such as ST-segment elevation, which may indicate acute myocardial infarction and require prompt intervention. Additionally, elevated cardiac biomarkers such as troponin or creatine kinase may suggest myocardial injury and hemodynamic instability such as hypotension or tachycardia may necessitate close monitoring and aggressive intervention.
In this particular case, there were no such high-risk features including ST-segment elevation or elevated troponin levels to suggest acute coronary syndrome that would require any procedures during the hospital stay.
The patient remained hemodynamically stable all the time. By the time the patient was seen by the admitting physician the chest pain resolved. The cardiac monitoring did not reveal any evidence of arrhythmias of immediate concern. Therefore, the inpatient stay was not medically necessary.