Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Acute inpatient admission

The insurer denied coverage for the acute inpatient admission.

The denial is upheld. 

This is a male patient who presented to the hospital complaining of chest pain that had been present for one week. It was described as constant and on his left-side. The patient had a similar episode months prior, and went to another hospital for cardiac workup which was reported to be negative. The patient did not follow-up with his cardiologist and noticed shortness of breath (SOB) prior to going to the hospital. The patient had a family history of cardiac disease at a young age. The patient was a cigarette smoker and consumed alcohol several times a week. 

 The patient's vital signs included temperature 98.2, heart rate 77, blood pressure 135/88, respirations 20 and oxygen saturation 99%. No abnormalities were noted on his physical examination. The patient's electrocardiogram (EKG) showed normal sinus rhythm with sinus arrhythmia at 65 beats per minute (bpm). It was a normal EKG and there were no EKGs available for comparison. A follow-up EKG showed sinus bradycardia at 57 bpm, and was again a normal EKG. There was no interval change. The patient's troponins trended twice were all within normal limits as was his B-type natriuretic peptide (BNP). The patient's chest X-ray showed that the lungs were clear and there was no evidence of pleural effusion or pneumothorax. 

A coronary angiogram was performed and it showed the left main coronary artery was normal, the left anterior descending (LAD) artery showed minor luminal irregularities but no flow limiting lesions, the circumflex artery was normal and the right coronary artery (RCA) showed no evidence of disease. The vessel arose anomalously from the left sinus of Valsalva. There were no complications during this procedure. The final impression was anomalous RCA from the left and minor coronary artery disease (CAD). The patient was discharged home on day 4 of admission with instructions to see his doctor within 1 week to repeat bloodwork. The patient was also to see his gastroenterologist within 2 weeks to follow-up on his biopsy.

This patient presented to the Emergency Department (ED) with a complaint of chest pain that had been present for one week. In spite of this duration of pain, the patient's troponins trended twice were negative and his EKG repeated twice showed normal sinus rhythm and they were normal EKGs, with no ST-segment changes consistent with myocardial injury. The patient's chest Computed Tomography (CT) scan showed no evidence of pulmonary embolus and no coronary artery calcium. The patient had a nuclear stress test which did not show ischemia and he had a coronary angiogram, which showed abnormal origin of the RCA but no CAD. The patient's upper endoscopy showed severe esophagitis, which was most likely the cause of his symptoms. The patient was placed in a Telemetry unit at the time of his admission, which was not medically necessary. Literature recognizes the use of an observation unit for this type of patient. The patient could have been managed in an observation unit. Thus, inpatient admission was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for acute inpatient admission is not substantiated. The insurer's denial should be upheld.