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 male. He presented after having awoken with right-sided chest pain.

In the ER (emergency room) he was found to be in atrial fibrillation with LBBB (left bundle branch block). His chest pain increased with breathing and was reproducible.  Cardiac enzymes were negative for ACS (acute coronary syndrome). His CXR (chest x-ray) was also normal.

On exam, the patient did have a systolic murmur. He was known to have MR (mitral regurgitation) in the past. He had a history of atrial fibrillation and was assessed a risk score of 1. He had history of a conduction abnormality.

The patient was alert, oriented and comfortable. His vital signs were stable. He was admitted to telemetry and treated conservatively. He was discharged the next morning with diagnosis of atypical chest pain, likely musculoskeletal.

No, the Inpatient admission 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. It is highlighted in the orders for care.

In this case, the patient's symptoms were atypical and unlikely to be representative of acute coronary syndrome. His exam showed cardiac findings of known MR and previously seen aFib (atrial fibrillation) with BBB (bundle branch block). His exam also noted reproducible pain. Biomarkers and EKG (electrocardiogram) showed no evidence of acute ischemia ("abnormal EKG" was consistent with previous tracings). CXR was normal. Echocardiogram showed no wall motion abnormality. The physicians' treatment did not reflect any serious concern about patient's cardiac condition. Orders did not include medical therapy for ACS, such as IV (intravenous) heparin, dual anti-platelet inhibitors, high dose beta blockers or IV NTG (nitroglycerin). The working diagnosis was atypical chest pain likely musculoskeletal. This was also the final diagnosis.

The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only cardiac care that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of CAD (coronary artery disease). In fact, all tests showed absence of ischemia. While there was always a potential for an adverse event (and in this case a very low probability), one did not happen, and no actual treatment was added. Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS present.

All testing and therapy that were provided would have been appropriate, safe, and guidelines-consistent in a lower level of care. Thus, inpatient level of care was not medically necessary.

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