Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: Inpatient Hospitalization. 

The insurer denied coverage for inpatient hospitalization. 

The denial is upheld. 

The patient has a past medical history of diabetes mellitus, hypertension, asthma, obstructive sleep apnea, morbid obesity, tobacco abuse disorder, and opioid use disorder. He presented with two days of chest pain, palpitations, and diaphoresis. Although he participates in a methadone program, he had been using opioids, including the day prior to evaluation. 

The health care plan acted reasonably and with sound medical judgment, and in the best interest of the patient. The health care plan indicated that there was no medical need for inpatient treatment, and that this non-cardiac chest pain could have been evaluated under observation status. 

The hospital was initially acting in the patient's interest by aggressively and appropriately working up his chest pain, particularly given his risk factors. Initial workup included two negative troponins, and positive D-dimer with subsequent normal computed tomography angiogram (CTA), and stable electrocardiogram (EKG). He had many atypical features, including 1-2 days of constant pain, which reduced the likelihood further of this being an acute event.  The negative CTA has a high negative predictive value, indicating that no additional workup for the possibility of pulmonary embolism was necessary. 

The workup after admission appears to have been minimal, however, suggesting that the prolonged hospitalization was not used to any additional benefit and was not medically necessary. The serial troponins were never performed as planned, after the initial two undetectable levels effectively excluded myocardial infarction. There is no indication given as to whether the minor EKG abnormalities (bifascicular block; ie right bundle branch block and left fascicular block) represent a change from prior, but the EKG was stable in the hospital, and there were no EKG findings to suggest acute coronary syndrome. Essentially, there was no meaningful additional workup completed after the initial few hours of his care, indicating that his evaluation and treatment was essentially concluded during what would be considered an observation period.

There was also no justification for inpatient status seen in a review of Milliman care Guidelines (MCG) (Angina) as submitted by the hospital. None of the criteria in that document applied in any meaningful way to this patient. Acute coronary syndrome had been excluded. Alternative diagnoses (specifically pulmonary embolism) had been excluded. The additional hospital days were not used to exclude or evaluate any alternative diagnoses, nor to further evaluate the possibility of coronary disease. A pulmonary consult confirmed the prior diagnosis of obstructive sleep apnea and commented upon stable asthma, but no significant additional workup was completed beyond that. He remained hemodynamically stable. No acute cardiac intervention was necessary nor pursued. His diabetes did not appear to require any unusual treatment. 

For these reasons, an observation would have been most appropriate for evaluating this episode of the patient's chest discomfort. An inpatient admission was not warranted in this circumstance. 

Based on the above, the medical necessity for the inpatient hospitalization is not substantiated. The insurer's denial is upheld.