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 chest and right upper quadrant abdominal pain. His medical history was remarkable for hypertension and a pulmonary embolism diagnosed one month prior. His blood pressure was 171/84 millimeters of mercury (mmHg) with a heart rate of 79 beats/minute. His respiratory rate was 20/minute with a room air oxygen saturation of 98%. His physical exam was remarkable for right upper quadrant and epigastric tenderness. An electrocardiogram showed sinus rhythm with ST segment and T wave abnormalities that were unchanged compared to prior tracings. His serum troponin I level was .291 nanograms/milliliter (ng/ml). An abdominal and pelvic computed tomography (CT) scan showed sigmoid diverticulitis and a question of a right lower lobe pulmonary infarction that was confirmed by CT scan. The patient was treated with intravenous fluid, aspirin and antibiotics and was admitted to the hospital to rule out acute coronary syndrome. A repeat troponin I level was unchanged and a third level was .157 ng/ml. The patient was seen by a cardiologist who opined that acute coronary syndrome was unlikely. The patient was discharged. At issue is the medical necessity of an inpatient admission.

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

This patient presented with symptoms that were thought to possibly represent acute coronary syndrome (ACS). Observation until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with no ischemic electrocardiographic changes. While his serum troponin level was mildly elevated, there was not a significant delta troponin. No specific intervention for ACS was deemed necessary. The patient did not require intensive monitoring or infusion of intravenous cardioactive medications. The care he received did not require an inpatient admission and could have been provided at a lower level of care "observation" status. This approach has been shown to be both safe and cost-effective 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 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.

Per the Milliman Care Guideline, Chest Pain (ORG: M-89) document, indications for inpatient admission include hemodynamic instability (NOT MET), respiratory distress (NOT MET), chest pain indicative of serious diagnosis other than coronary artery disease (NOT MET) and angina or myocardial infarction. The reader is referred to guidelines for angina or myocardial infarction, which were not provided. However, the patient's symptoms were atypical for angina and he did not meet accepted clinical criteria for myocardial infarction.