Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Overturned

The patient is a male who presented to the emergency department with concerns of chest pain. Pertinent history included hypertension and tobacco abuse. Initial vital signs revealed a temperature of 97.9 Fahrenheit (F), heart rate (HR) 100, blood pressure (BP) 135/95, respiratory rate (RR) 21, peripheral capillary oxygen saturation (SpO2) 100% on room air. Initial examination documented the patient as alert and oriented. Initial laboratory testing revealed a white blood cell (WBC) count of 6.4, hemoglobin (Hgb) 14.7, platelets (Plt) 329, Troponin negative x 3, brain natriuretic peptide (BNP) within normal limits (WNL), sodium (Na) 139, potassium (K) 4.4, blood urea nitrogen (BUN) 16, creatinine (Cr) 1.0. Electrocardiogram (EKG) was without acute ischemic changes. Chest radiograph was unremarkable.
The patient was admitted with an impression of atypical chest pain with a Heart score of 1. Treatment plan included telemetry and echocardiogram.  Echocardiogram was relatively unremarkable. Treatment plan was updated to include a cardiac stress test. The stress test was abnormal. Cardiology consulted and recommended a cardiac catheterization. Chest discomfort continued. Amlodipine and long-acting nitrate was added. A cardiac catheterization was performed which did not reveal obstructive coronary artery disease. The patient tested positive for Coronavirus 2019 (COVID-19) and was documented as asymptomatic. He was deemed medically stable and discharged. The subject under review is the medical necessity for the inpatient hospital admission.

The requested inpatient hospital admission was medically necessary for this patient. 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.
The patient had a history of cardiac risk factors and presented with chest discomfort and shortness of breath. The initial electrocardiogram was unremarkable. Serial troponins were negative. Chest radiograph was unremarkable. An echocardiogram was unremarkable. A cardiac stress test was performed with resting perfusion abnormalities concerning for reversible ischemia. During this diagnostic evaluation, chest pain persisted, and nitrates were initiated to address such. Cardiology consulted and recommended pursing a left heart catheterization. This was performed and was unremarkable for obstructive coronary artery disease but did not a myocardial bridge in the mid-left anterior descending (LAD). On the day of discharge, a COVID-19 test was performed per patient request and returned positive. No other issues or complications were documented.
Moreover, clinical indications for admission to inpatient care were met. The patient did have new onset chest pain and dyspnea suspected to be due to myocardial ischemia that occurred with exertion without evidence of acute cardiomyocyte necrosis. Invasive treatment with intent to revascularize if appropriate was warranted due to tachycardia and intermediate-risk cardiac ischemic findings on noninvasive testing.[2]