Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male who presented with right sided chest pain and risk factors for coronary artery disease (CAD) of hypertension, smoking, hyperlipidemia, borderline diabetes and positive family history. The patient's initial blood pressure was elevated at 160/100. His electrocardiogram (EKG) showed sinus rhythm and left anterior fascicular block (LAFB) without acute changes. The patient was given aspirin (ASA) and was admitted to telemetry. The patient was prescribed aspirin initially, then Losartan. Deep vein thrombosis (DVT) scan, echocardiogram and nuclear stress test were ordered. Doppler scan did reveal thrombus and the patient was started on Eliquis. There was no evidence of myocardial infarct (MI) or acute coronary syndrome (ACS) and the patient was discharged.
The appeal letter stated that the care that patient received could not be done as an outpatient. The letter also stated that the patient had increased risk of coronary artery disease. Inpatient level of care was denied.

The proposed treatment was not medically necessary.

Inpatient level of care was not necessary or provided. 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 normal. Biomarkers and electrocardiogram showed no evidence of acute ischemia. Chest x-ray was normal. Echocardiogram showed no wall motion abnormality. 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 heparin, dual antiplatelet inhibitors, high dose beta blockers or intravenous nitroglycerin (NTG). 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. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. The statement 
that this patient could not be "managed" in an outpatient setting is not consistent with guidelines or usual community practice. 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 (and in this case a low probability), one did not happen, and no actual treatment was added. There are no 
examples of care requiring inpatient level of care. Milliman criteria requirements for admission for unstable angina were not fulfilled as there was never any evidence of acute coronary syndrome present. Since all testing and therapy would be 
appropriate, safe and guidelines consistent in a lower level of care, inpatient level of care was not medically necessary. The denial explanation is consistent with guidelines and usual community care.