Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient presented to the emergency department complaining of 1-2 hours of intermittent chest pain, anxiety, dyspnea and marked blood pressure elevation. Her medical history was remarkable for hypertension, diabetes, hyperlipidemia and morbid obesity. She admitted to noncompliance with her prescribed antihypertensive regimen; however, she did take a dose of metoprolol before calling Emergency Medical Services (EMS) for transport to the hospital. EMS found her blood pressure to be 201/100 millimeters of mercury (mmHg) and administered a dose of aspirin. In the emergency department (ED), the patient's blood pressure was 163/63 millimeters of mercury (mmHg) with a heart rate of 94 beats/minute. Her respiratory rate was 18/minute with a room air oxygen saturation of 100%. The patient's cardiac and neurologic exams were unremarkable. Her electrocardiogram showed sinus rhythm and was a normal tracing. Her serum troponin I level was .27 nanograms/milliliter (ng/ml) and was .28 ng/ml when rechecked. Her serum creatinine level was 0.7 milligrams per deciliter (mg/dl). She had a microcytic anemia with a hemoglobin of 8 mg/dl. While in the ED, the patient reported that her chest pain had resolved. Her blood pressure gradually decreased to 129/76 mmHg. She was admitted to the hospital. A cardiac stress test was recommended. However, the patient declined to stay in the hospital and left against medical advice. At issue is the medical necessity of an inpatient stay.

Based on the documentation provided, an inpatient level of care was not medically necessary.

This patient presented with uncontrolled hypertension due to medical noncompliance and had complaints of chest pain. Given the concern for acute coronary syndrome, admission for evaluation and treatment was a reasonable approach. While the patient was initially markedly hypertensive, her blood pressure gradually decreased to normal levels and there was no evidence of acute end organ damage. Her serum troponin level was mildly elevated but there was no significant delta troponin and her electrocardiogram was normal. Given the lack of a significant delta troponin and the normal electrocardiogram, this patient did not meet accepted criteria for a diagnosis of myocardial infarction. She did not require intensive monitoring or continuous infusion of intravenous cardioactive medications. The care she received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with current guidelines, including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.

It should be noted that the patient had a significant anemia. Since this was not addressed in the records provided it appears that the patient was not thought to have a source of acute blood loss which, if present, might have warranted an inpatient level of care.