Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a male who presented to emergency department (ED) as a transfer from urgent care with right sided chest pain. The patient was complaining of chest pain with inspiration on the right and posterior part of his chest. The pain started on the day of presentation, felt sharp, stabbing in nature, lasting seconds, and worsened with deep inspiration.
The pain started in the evening. The patient also was complaining on worsening shortness of breath. The patient reported that he felt sensation of fluid moving in the basal portion of his right lung.
The patient has history of viral myocarditis, dilated cardiomyopathy, history of cardiac arrest , antiphospholipid syndrome and retinal emboli. The patient has history of medication noncompliance and was not taking carvedilol and ramipril. The patient has an implantable cardioverter defibrillator (ICD) in place. The patient was on Xarelto.
The patient was evaluated in ED. His blood pressure (BP) was 128/62, his heart rate (HR) was 63 and temperature was normal. His O2 (oxygen) saturation was 98% on room air. His electrocardiogram (ECG) revealed sinus bradycardia.
His troponin was 0.111, platelets 125, international normalized ratio (INR) 1.67, and bilirubin
1.8. His Chest computed tomography angiography (CTA) was negative for pulmonary embolism (PE). There was no acute pulmonary pathology.
The patient received intravenous (IV) fluid bolus and aspirin 325 milligrams (mg).
The patient was complaining on worsening chest pain. The patient was admitted to the hospital for evaluation for possible myocardial infarction (MI).
The patient felt congested and he was trying to cough up mucus but was not able. He reported that rapid COVID test was negative. The patient was monitored on telemetry. The patient was given oral Lisinopril and carvedilol, He also continued on Xarelto. His repeated troponin was 0.019.
His echocardiogram revealed mild left ventricular (LV) systolic dysfunction with ejection
fraction (EF) 45-50%. His LV was mildly dilated. There was trace mitral and tricuspid
regurgitation. Right ventricular size and function was normal. The patient was monitored on telemetry and noted sinus bradycardia.
The patient was consulted by cardiology. The impression was that his chest pain was pleuritic in nature and his elevated troponin was due to demand ischemia. The ECG and telemetry was not concerning for acute coronary syndrome (ACS), acute ardiomyopathy or myocarditis.
The Inpatient Hospital Admission was not medically necessary for this patient.
The patient presented with atypical chest pain, with features suggestive for pleuritic chest pain. There was no evidence for acute coronary syndrome, pneumonia or pericarditis, based on chest computed tomography (CT), echo and electrocardiogram (ECG). His troponin was minimally elevated and cardiology contributed it to demand ischemia. The patient's condition was stable, and he was treated with oral medications. There were no major diagnostic or therapeutic interventions done. The patient's condition and his care did not meet criteria for inpatient admission. A lower level of care was more appropriate for this episode of care.