Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This patient is a homeless male with a history of alcohol use disorder, bipolar disorder, depression, hypertension (HTN) and gout.  He has a history of frequent emergency department (ED) presentations for alcohol intoxication, withdrawal, and seizures.  He presented to the emergency department complaining of intermittent left sided chest pain radiating to back. He had been seen earlier and was found to have troponin .05, .03 and magnesium (Mg) 1.2.  

The patient's vital signs (VS) were as follows: temperature 98.3, pulse 103, respiratory rate 18, blood pressure 161/111, and oxygen saturation 99% room air (RA). The patient's exam was remarkable for mild tremors on extended fingers, mild tongue fasciculations, and mild anxiety.  Labs revealed the following: hemoglobin/hematocrit (H/H) 11.2/32.3, platelets (plt) 162, sodium (Na) 144, potassium, (K) 3.8, carbon dioxide (CO2) 27, and blood urea nitrogen (BUN) / creatinine (Cr) 9 / 0.8. The patient's electrocardiogram (EKG) showed no ischemic changes.  

The patient was admitted.  Plan of care included serial troponin and electrocardiogram (EKG); serial Clinical Institute Withdrawal Assessment for Alcohol (CIWA); and replete magnesium (Mg).  The following day, the patient is noted to have chronic non cardiac chest pain.  Day 3, the patient's vital signs were stable (VSS) and the patient was afebrile.  Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was 7.  The patient continued to have chest pain and abdominal pain.  He had not had a bowel movement (BM) in two days.  Chest x-ray (CXR)  revealed no acute disease (NAD).  Plan was for librium as needed (PRN) and outpatient cardiology evaluation.  Day 3, the patient's vital signs were stable (VSS).  The patient was given librium overnight for possible withdrawal.  Naltrexone was started. The patient was to start Maalox.  Day 4, the patient was cleared for discharge.

No, the proposed treatment was not medically necessary.
Medically necessary services are those which are:
1) safe 
2) effective
3) generally accepted national standard of medical practice 
4) not provided primarily for convenience of the patient or the practitioner 
5) the least intensive and/or most appropriate alternatives among diagnostic and treatment option.

This is a patient with multiple medical conditions including alcohol use disorder.  The patient was admitted after presenting with chest pain. The patient was hemodynamically stable and had normal oxygenation. At the time of admission, he had mild tachycardia.  He had mildly elevated troponins, but no ischemic changes on electrocardiogram (EKG).  The patient was admitted to rule out acute coronary syndrome (ACS).  During hospitalization, he was treated with benzodiazepines and naltrexone for mild alcohol withdrawal.  He remained hemodynamically stable and did not have evidence of severe withdrawal that would require an acute inpatient level of care.  Management of patients with complaints of chest pain, but with non-diagnostic electrocardiogram and cardiac biomarkers inconsistent with acute coronary syndrome is emergency department observation.  This patient's evaluation did not produce diagnostic studies supporting chest pain due to acute coronary syndrome (ACS).  The patient's workup for atypical chest pain could have been managed at a lesser level of care.  During the hospital stay, the patient did not receive intervention that required an acute inpatient level of care.  The requested Inpatient Hospital Admission was not medically necessary.