Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems-Chest Pain. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld in whole. 

This patient is a male admitted for a diagnosis of chest pain. The patient presented with retro-sternal chest pain and questionable lower gastrointestinal (GI) bleed. His chest pain started three days prior to admission. His vital signs demonstrated a blood-pressure at 111/69, pulse was 88, respiratory rate was 18, temperature was 98.1 and pulse oxygen saturation was 98%. The physical exam showed no altered mental status with some distress due to pain. 

His hemoglobin was 12.5 with creatinine at 1.83. The arterial blood gas (ABG) showed a potential hydrogen (pH) at 7.4 with a partial pressure of carbon dioxide (PCO2) at 23. The brain (or B-type) natriuretic peptide (BNP) was 71. The patient had serial cardiac enzymes which remained negative. The electrocardiogram (EKG) showed no segment (ST) or T-wave changes. 

The patient received medications including Nitroglycerin, Lipitor, Coreg, and his chest pain resolved. The echocardiogram showed a normal systolic function. An acute coronary syndrome was excluded as a diagnosis. The patient did have one episode of hematochezia and his hemoglobin dropped to 11.9. An esophagogastroduodenoscopy (EGD) and colonoscopy were done which showed esophagitis and gastritis. The patient also had an internal hemorrhoid and was started on Protonix daily. 
At issue is the medical necessity of the inpatient stay. 

The health plan's determination of medical necessity is upheld in whole. 

The health service/treatment of inpatient stay was not medically necessary for this patient. 

According to UptoDate, 2020: "Disposition, Any patient with hemodynamic instability or significant respiratory distress is admitted to the intensive care unit (ICU). Patients with acute aortic dissection, pneumothorax, cardiac tamponade, and mediastinitis require admission and appropriate consultation. (See "Management of acute aortic dissection" and "Pneumothorax in adults: Epidemiology and etiology" and "Cardiac tamponade" and "Boerhaave syndrome: Effort rupture of the esophagus")." 
The patient in this case had chest pain but did not have acute coronary syndrome established as a diagnosis. The patient did not have aortic dissection, pneumothorax, tamponade, or mediastinitis. The patient did not have pulmonary embolism, hemodynamic instability, or hypoxia. The patient did not have a ST-Elevation Myocardial Infarction (STEMI) or a non-ST elevation myocardial infarction (NSTEMI). 
The patient in this case did not have hemodynamic instability, persistent bleeding, significant comorbid illness, advanced age, or bleeding that started during the hospital stay. The patient did not have diverticulosis, abnormal coagulation time, hypoalbuminemia, and there was no epigastric tenderness on the initial physical exam. The patient had mild anemia but no elevated blood urea nitrogen (BUN) or abnormal white blood cell count. The patient did not have diarrhea. 

Therefore, the inpatient stay was not medically necessary.