Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with coronary artery disease (CAD) (stent), asthma/chronic obstructive pulmonary disease (COPD), substance abuse (cocaine), tobacco use, obesity, and gastritis who presented to the emergency department (ED) with severe chest pain, nausea and vomiting, dyspnea and productive cough over the two days prior to admission. She apparently had multiple admission for similar symptoms in the year prior to this admission. 

She was afebrile, with blood pressure (BP) of 145/90, heart rate (HR) 105, and respiratory rate (RR) 18, saturating 100% on room air (RA). Her chest was tender to touch. She was breathing comfortably with minimal wheeze. Labs were notable for white blood cell (WBC) count of 11, blood urea nitrogen (BUN)/creatinine (Cr) 18/0.73, and troponin was 0.0. Chest x-ray (CXR) was clear. Electrocardiogram (ECG) found no ischemic changes. 

She was admitted to cycle cardiac enzymes. Although the concern for acute coronary syndrome was low, a stress test was planned, and she was placed on telemetry. She received pain medication. For the COPD flare, her peak flow was slightly below her baseline. She was started on intravenous (IV) steroids, azithromycin, and nebulized bronchodilators. She was seen by cardiology who also felt this was likely costochondritis.
By day two of admission, the chest pain had resolved. Vitals were normal. Troponins were negative. A stress test was planned. IV steroids and azithromycin were continued. On day 3 she continued to do well with no pain or dyspnea and normal vitals. Her nuclear stress was negative. She was discharged the next day with azithromycin and prednisone. 

The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld.

No, an inpatient stay was not medically necessary for this patient. Her risk of a bad outcome, the need for close monitoring, and the need for inpatient only treatments were all low. She presented with two possible problems, chest pain and COPD exacerbation. Her chest pain was quite atypical and was felt by both the primary team and the cardiology consult to probably represent costochondritis. Her electrocardiogram (ECG) and initial troponin were negative, and her history was atypical. Two regularly used scoring systems (thrombolysis in myocardial infarction [TIMI] risk index and HEART score) both suggested a low risk of mortality or major cardiac events. Her troponin levels remained negative on repeat testing. Her symptoms had resolved completely by day two of admission. Given the low risk of mortality or a major cardiac event, negative routine testing, and resolution of symptoms within 24 hours of admission, she did not need ongoing close monitoring, inpatient only testing or treatment. 

Her COPD exacerbation was quite mild. She was not in respiratory distress and had no significant gas exchange abnormality. Her peak flow was minimally reduced compared to baseline. She had no evidence of other organ dysfunction (encephalopathy, hemodynamic instability, respiratory failure, acute kidney injury [AKI], electrolyte abnormality, etc.). Her symptoms resolved with observation care. Her BAP-65 and DECAF scores suggested a low risk of her COPD flare leading to mortality or need for mechanical ventilation. 

As her symptoms were not severe at presentation, her risk of worsening was low, and she improved with observation care, it was reasonable for her to be monitored for improvement, but she did not need an inpatient admission. She did not need close surveillance or inpatient only treatments.