Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain; Dyspnea.
Treatment: Inpatient Admission.

The insurer denied inpatient admission. The denial is upheld.

The patient is an elderly male. He has multiple risk factors for coronary artery disease (CAD), including hypertension, hyperlipidemia, diabetes mellitus, and peripheral arterial disease (PAD). His past medical history is positive for peripheral arterial disease, percutaneous transluminal angioplasty (PTA), and multiple percutaneous coronary interventions (PCIs). He presented with chest pain and dyspnea that lasted 15 minutes. He had a history of intermittent chest pain in the past. The patient's electrocardiogram (EKG) was described as abnormal, not a ST-elevation myocardial infarction (STEMI). He was admitted and monitored in telemetry. His pain resolved. He was discharged on guideline-directed medical therapy (GDMT). He did have a subsequent catheter at a later date that showed significant coronary artery disease (CAD). The inpatient admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The inpatient admission was not medically necessary.

Determination of the level of care primarily depends on the actual care that a patient receives and whether a higher acuity level is needed to give this care. This is reflected best in the presentation, physical exam findings, laboratory orders, and their results, and is highlighted in the orders for care. In this case, the patient's symptoms were atypical and unlikely to represent acute coronary syndrome. The patient's exam and cardiac findings were normal. Biomarkers and electrocardiograms showed no evidence of acute ischemia. The physician's treatment did not reflect serious concern about the patient's cardiac condition. Orders did not include medical therapy for acute coronary syndrome (ACS), such as intravenous heparin, dual antiplatelet inhibitors, high-dose beta-blockers, or intravenous nitroglycerin (NTG). The only care provided was monitoring and telemetry. The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, which is frequently performed at a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. The statement that this patient could not be safely managed in an outpatient setting is not consistent with guidelines or usual community practice. This patient had no evidence of active coronary artery disease. In fact, all tests showed the absence of ischemia. While there was always a potential for an adverse event, one did not happen, and no actual treatment was added. There are no examples of care requiring an inpatient level of care.

Milliman criteria requirements for admission for unstable angina were not fulfilled, as there was never any evidence of acute coronary syndrome present. Since all testing and therapy would have been appropriate, safe, and guideline-consistent to have been provided in a lower level of care, inpatient level of care was not medically necessary. The denial explanation was consistent with guidelines and usual community care.