Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient who presented to the emergency department (ED) complaining of uncontrolled hypertension with systolic blood pressures greater than 200 millimeters of mercury (mmHg), dyspnea and left-sided chest pain. She had been seen the day prior but left the hospital against medical advice. Her medical history was remarkable for hypertension and diabetes. In the emergency department (ED), her blood pressure was 181/110 millimeters of mercury (mmHg) with a heart rate of 102 beats/minute. Her room air oxygen saturation was 98 percent (%). An electrocardiogram showed sinus rhythm without acute changes. Her serum troponin and brain (or B-type) natriuretic peptide (BNP) levels were normal. A chest computed tomography (CT) scan showed no evidence of aortic dissection or pulmonary embolism. There were several small pulmonary nodules and bilateral adrenal nodules but no acute findings. The patient was treated with intravenous labetalol and oral carvedilol. Her repeat blood pressure was 154/56 millimeters of mercury (mmHg). She was admitted to the hospital. An echocardiogram showed severe left ventricular hypertrophy and a left ventricular ejection fraction of 50 percent (%). Her antihypertensive regimen was adjusted. She was discharged. At issue is the medical necessity of an inpatient stay.

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

This patient presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until acute coronary syndrome (ACS) could be ruled out was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received for her chest pain did not require an inpatient admission and could have been provided under 'observation' status. This approach has been shown to be safe 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 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.

Upon presentation, the patient was markedly hypertensive. However, there was no evidence of acute end-organ damage and based on the records provided, an inpatient level of care was not medically necessary for blood pressure management. There is no evidence that rapid lowering of blood pressure in patients with hypertensive urgency is of benefit and, it can be harmful. Outpatient titration of antihypertensive medications with lowering of blood pressure to goal over a period of weeks has been shown to be both safe and effective.