Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission
The denial is overturned.

The patient is a male who presented to the emergency department with concerns of chest pain of one week duration. Pertinent history included gastroesophageal reflux disease, tobacco abuse, chronic back pain. Initial vital signs revealed a temperature of 97.9 Fahrenheit (F), heart rate (HR) 68, blood pressure (BP) 118/79, respiratory rate (RR) 18, peripheral capillary oxygen saturation (SpO2) 100% on room air.

Electrocardiogram (EKG) was without acute ischemia. Initial laboratory testing revealed a white blood cell (WBC) count of 7.6, hemoglobin (Hgb) 14.5, creatinine (Cr) 1.27, Troponin I 0.048 (less than [<] 0.031). Drug screen positive for tetrahydrocannabinol (THC). Chest radiograph unremarkable. Computed tomography angiography (CTA) chest unremarkable. Cardiology consulted who noted concerns for unstable angina. Plavix load and therapeutic Lovenox was provided. The patient proceeded to leave the emergency department to get some dinner and then returned. The following day the patient denied any acute concerns. Repeat troponins were 0.041 and 0.056. Cardiology recommended proceeding with a left heart catheterization due to concerns for unstable angina, but the patient again left against medical advice. The subject under review is the medical necessity for the inpatient hospital admission.

Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was indicated as medically necessary for the entire admission.

McConaghy et al. note the initial goal in patients presenting with chest pain is to determine if the patient needs to be referred for further testing to rule in or out acute coronary syndrome and myocardial infarction. The physician should consider patient characteristics and risk factors to help determine initial risk. Twelve-lead electrocardiography is typically the test of choice when looking for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new-onset T wave inversions. For persons in whom the suspicion for ischemia is lower, other diagnoses to consider include chest wall pain/costochondritis (localized pain reproducible by palpation), gastroesophageal reflux disease (burning retrosternal pain, acid regurgitation, and a sour or bitter taste in the mouth), and panic disorder/anxiety state. Other less common but important diagnostic considerations include pneumonia (fever, egophony, and dullness to percussion), heart failure, pulmonary embolism (consider using the Wells criteria), acute pericarditis, and acute thoracic aortic dissection (acute chest or back pain with a pulse differential in the upper extremities).[1]

The patient presented to the emergency department with concerns of exertional chest pain. The patient ambulated 7000-8000 feet routinely, but became limited within the past several days due to chest pain. The patient was evaluated the day prior and discharged home, however, returned as pain returned quicker than prior. Initial EKG was unremarkable but the troponin was slightly elevated. Troponins remained minimally elevated and flat. Cardiology consulted and noted concerns for unstable angina. Plavix load and therapeutic Lovenox were provided. A left heart cardiac catheterization was scheduled but the patient left against medical advice. Moreover, clinical indications for admission to inpatient care were met. [2]