Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male with a past medical history significant for hypertension, cerebrovascular accident (CVA), Graves' disease, and chronic back pain who presented to the emergency department with acute onset of chest tightness and shortness of breath, which had been going on for 1 day.
It was reported that over the course of one week the patient had 3 episodes of chest tightness and shortness of breath associated with dizziness. All 3 episodes occurred when the patient was at rest. Each episode lasted for 15-20 minutes and resolved without any intervention.
The most recent episode occurred on the day of admission and was associated with chest tightness, difficulties breathing, and dizziness. Apparently, his chest pain radiated to the left shoulder joint.
When the patient was evaluated in the emergency department, he was afebrile. The blood pressure was 180/115, pulse rate was 89 beats per minute (bpm), respiratory rate was 16 breaths per minute, and oxygen saturation was 96% on room air. The patient was an obese male who was lying in bed in no acute distress. His lungs were clear to auscultation bilaterally. He had a regular heart rate and rhythm without murmurs, rubs, or gallops. The abdomen was non-tender and non-distended, with normoactive bowel sounds. There was no lower extremity edema.
Laboratory evaluation revealed that white blood cell count was 7.1, hemoglobin was 13.0, hematocrit was 39.5, and platelets were 204. Sodium was 141, potassium was 3.8, chloride was 106, bicarbonate was 23, blood urea nitrogen (BUN) was 15, creatinine 1.13. Troponin was 0.01.
In the hospital, the patient underwent a computed tomography (CT) angiogram of the chest, which was negative for pulmonary embolism. The patient underwent a transthoracic echocardiogram, which was unremarkable.
The patient was evaluated by a cardiologist who recommended no further workup since the chest pain looked atypical.
While in the hospital, the pain resolved.
During the hospital stay, the patient remained in normal sinus rhythm but slightly bradycardic, therefore the dose of metoprolol was decreased.
Since the patient remained in satisfactory clinical condition, he was discharged home with a recommendation to follow up with a primary care physician in one week after discharge.
The subject under review is the medical necessity for an inpatient stay.

The health plan's determination is upheld in whole.

Based on the accepted standards of care, admission for evaluation and treatment of chest pain at the acute inpatient level of care is usually required in cases when chest pain is associated with hemodynamic instability, persistent respiratory distress, also when chest pain is indicative of serious diagnosis other than coronary artery disease. Another indication for admission at the acute inpatient level of care is when chest pain is associated with unstable angina or myocardial infarction. The review of the medical records clearly demonstrated that the patient had none of the circumstances listed above.
During this hospital stay, it was determined that the patient's chest pain was atypical without alarming features. This patient did not require any procedures or diagnostic tests that would necessitate admission at the acute inpatient level of care. The patient could have been managed at a lower level of care status.