Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with presentation of atypical chest pain, treated with nitroglycerin (NTG) and aspirin (ASA) without relief.  The patient has a history of gastroesophageal reflux disease (GERD), is a former smoker, and denies previous heart disease or major risk factors. 

The patient's vital signs were stable (VSS), exam was normal, and labs were normal. There were multiple unifocal premature ventricular contractions (PVCs) but no ventricular tachycardia (VTach), or significant pauses. The patient was given Maalox and intravenous fluids (IVF). The patient had premature ventricular contractions (PVCs) with no acute changes. Nuclear stress test was normal. There was no evidence of acute coronary syndrome (ACS). The patient was discharged with a diagnosis of atypical chest pain and gastroesophageal reflux disease (GERD).

No, the proposed inpatient level of care was not medically necessary.
Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome. Exam and cardiac findings were negative for acute coronary syndrome (ACS). Biomarkers and electrocardiogram (EKG) showed no evidence of acute ischemia ("abnormal EKG" was borderline, just PVC's).  The patient's chest x-ray (CXR) was normal. Her nuclear scan was negative for coronary artery disease (CAD). The physicians' treatment did not reflect any serious concern about the patient's cardiac condition.  Orders did not include medical therapy for acute coronary syndrome such as intravenous (IV) heparin, dual anti-platelet inhibitors, high dose beta blockers or intravenous nitroglycerin.  

Premature ventricular contractions (PVCs), though frequent, are not malignant and rarely cause acute issues. Investigation and treatment is best accomplished as an outpatient.

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. This patient was admitted for monitoring but subsequent tests and therapy did not require an inpatient level of care.

There was no "complex" care that required inpatient level of care. This patient had no evidence of coronary artery disease. All tests showed absence of ischemia.  While there is always a potential for an adverse event, one did not happen and no actual treatment was added.

Milliman criteria requirements were not fulfilled as there was never any evidence of acute coronary syndrome present.

All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, the inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.