Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is: Upheld

The patient is a male who presented to the emergency department with concerns for chest pain. Pertinent history included a physical altercation with trauma to the chest on the day of presentation. Additional history included coronary artery disease, cardiac arrest status/post (s/p) automatic implantable cardioverter defibrillator (AICD), diabetes mellitus, hypertension, and opioid dependence.

Initial vital signs revealed a temperature of 98.4 Fahrenheit (F), heart rate (HR) 108, blood pressure (BP) 189/103, respiratory rate (RR) 18, peripheral capillary oxygen saturation (SpO2) 99% on room air. Initial examination did not document chest tenderness. Initial electrocardiogram (EKG) did not reveal acute ischemic changes. Initial laboratory testing revealed a white blood cell (WBC) count 8.9, hemoglobin (Hgb) 15.6, platelets (Plt) 208, blood urea nitrogen (BUN) 24, creatinine (Cr) 0.9, glucose (Glu) 241, sodium (Na) 138, potassium (K) 4.8, brain natriuretic peptide (BNP) 479, Troponin negative. Chest radiograph unremarkable. The patient was admitted with an impression of atypical chest pain, likely musculoskeletal in nature. Treatment plan included serial cardiac enzymes, resumption of home oral medications, telemetry, and cardiology consultation. Hemodynamics were stable and serial cardiac enzymes were negative. Cardiology consultation was obtained who had an impression of musculoskeletal pain from trauma during physical altercation. Recommendations were to discharge home with no further cardiac evaluation indicated. The patient was discharged thereafter. The subject under review is the medical necessity for the inpatient admission.

The inpatient admission was not medically necessity.
Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care status.

In this particular situation, the patient presented to the emergency department with chest pain after a physical altercation with trauma to the chest. Initial evaluation followed the aforementioned guidelines and was essentially unremarkable. EKG was relatively unremarkable, telemetry was relatively unremarkable, chest radiograph was unremarkable, and serial cardiac enzymes were unremarkable. The admitting physician had an impression of likely musculoskeletal chest pain. Following monitoring, a cardiology consultation was obtained who agreed with musculoskeletal chest pain from the physical altercation and did not recommend any further cardiac evaluation. No other issues or complications were documented.
Moreover, clinical indications for admission to inpatient care were not met. The patient did not have hemodynamic instability, respiratory distress, pulmonary edema most likely due to ischemia, new or worsening mitral regurgitation murmur, third heart sound, new or worsening rales, new transient ST-segment deviation of 0.5 millimeter (mm) or more on electrocardiogram (ECG), recurrent or refractory ischemic symptoms despite treatment, or intermediate or high-risk ischemia findings on noninvasive testing.[2] In addition, the patient had no evidence of a myocardial infarction and expert consultation by a cardiologist did not feel this was an acute coronary syndrome.[3]