Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is: Upheld

The patient is a male with a past medical history significant for myocardial infarction, heroin use, chronic sinus bradycardia, gastroesophageal reflux disease (GERD), constipation, and schizophrenia who presented to the hospital with substernal chest pain after a reported assault. The patient stated that he was beaten with a baseball bat and lost consciousness for an unknown period of time.
When seen by the admitting physician the patient complained of mild diffuse headache and substernal chest pain. He rated the chest pain as 6/10 in severity, non-radiating, and relieved by medications given in the emergency room (ER). The patient denied direct impact to the chest during the assault.
The review of systems was positive for chronic "slow breathing" and diffuse abdominal pain, which was attributed to chronic constipation. The patient denied nausea, vomiting, or any neurological deficits. The admitting physician stated that the patient was not in any distress at the time of the examination.
On the physical exam, the patient was in no acute distress. 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. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. There was abdominal tenderness in the right upper quadrant, epigastrium, and left upper quadrant. The rest of the physical exam was unremarkable.
Chest x-ray showed no evidence of pneumoperitoneum, widened mediastinum, or rib fractures. Computed tomography (CT) scan of the head showed no acute intracranial abnormality. CT of maxillofacial bones showed no acute fracture or dislocation. Electrocardiogram (EKG) demonstrated normal sinus rhythm. There was no evidence of acute changes consistent with the acute coronary syndrome.
The patient was admitted to the hospital with substernal chest pain to rule out acute coronary syndrome. During the hospital stay, the patient was seen by an electrophysiologist who was consulted for the evaluation of chronic bradycardia. The patient was recommended to avoid atrioventricular nodal (AVN)-blocking medications. Since the patient had prolonged corrected QT (QTc) interval, the dose of Methadone that the patient took chronically was reduced. Following this, the patient insisted that he would like to get his usual dose of Methadone, despite understanding the risk of possible complications related to prolonged QTc interval. Therefore, his usual dose of Methadone was reinstated.
At the end of the hospitalization, the patient decided to leave the hospital against medical advice. At that time, the patient was alert and oriented.

The health plan's determination is upheld.

The inpatient admission was not medically necessary for this patient.
The patient was admitted to the hospital with substernal pain to rule out acute coronary syndrome and chest trauma. The review of the medical records clearly demonstrated that the chest pain that was associated with the assault did not cause hemodynamic instability or respiratory distress. There was no clinical evidence that the patient had typical angina or myocardial infarction.
The EKG did not demonstrate any acute changes suspicious for the acute coronary syndrome. 
Taking into consideration all these facts, there are no indications that either the severity of the patient's condition or the complexity of services provided rose to the acute inpatient level of care. Admission of the patient for monitoring to rule out acute coronary syndrome or any other serious conditions causing chest pain and syncope was necessary, however this evaluation could have been conducted at a lower level of care status.