Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain  
Treatment: Inpatient Hospital Stay  

The insurer denied an inpatient hospital stay. The determination is upheld.  

The patient presented to the emergency department by ambulance for an emergency evaluation due to chest pain and back pain.  He reported back pain for 5 days and chest pain for two days.  His chest pain was dull and left sided, rated a ten out of ten.  There were no provoking or relieving factors (by another note, it was worse with movement). The patient also reported orthopnea and shortness of breath.  

The patient has a history of coronary artery disease (CAD) with stent placement in the left anterior descending (LAD), diabetes mellitus (DM), hyperlipidemia, hypertension, congestive heart failure (CHF) depression, obesity, diabetes mellitus (DM), obstructive sleep apnea (OSA) on continuous positive airway pressure (CPAP), asthma, ethyl alcohol (ETOH) abuse and peripheral artery disease.  

The patient recently underwent a coronary angiogram, and it revealed triple vessel disease.  He has a reduced ejection fraction (EF) of 35-40%, based on the echocardiogram.  The right ventricular systolic pressure was 55 millimeters of mercury (mmHg).  There was biatrial dilatation, mild mitral regurgitation, and moderate tricuspid regurgitation.  The patient used to walk a full block, but now he can only manage half a block.  He also endorsed orthopnea.  

In the ED, his vital signs were normal.  His physical examination was unremarkable.
His chest x-ray (CXR) revealed "Enlarged cardiac silhouette, small infiltrate right lower lobe posteriorly overlying lower thoracic spine on lateral view".  His brain (or B-type) natriuretic peptide (BNP) was elevated to 1790 and creatine kinase (CK) was 245.  His troponin was normal.  His transaminases were elevated.  It was contributed to by ETOH abuse. 

His ECG did not have ischemic changes.  An x-ray of the lumbar and thoracic spine was negative.  The patient was admitted to the hospital on a telemetry floor.
His home medications were continued.  A cardiology consultation was obtained and recommended medical management with anti-anginal, optimal medical therapy with reduced EF.  The diagnosis was chest pain, CHF, chronic systolic, hypertension controlled.  Medical management for chronic angina, and Lasix to treat the CHF were recommended. 

At issue is the medical necessity of an inpatient stay.  The inpatient stay was not medically necessary for this patient. 

The patient presented with chest pain and worsening dyspnea.  He has multiple coronary risk factors and previous coronary and peripheral vascular intervention.  However, during this admission, there was no evidence of acute coronary syndrome.  His troponin was normal.  His ECG did not have ischemic changes.  His chest pain was atypical.  Because the patient had a relatively recent echocardiogram and cardiac catheterization, the studies were not repeated.  The cardiology service did not feel that additional cardiac studies warranted.  His heart failure also was chronic and under control.  His condition remained stable.  The patient was treated with oral medications.  Based on above information, an inpatient level of care was not warranted.  A lower level of care would have been more appropriate.