Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain 
Treatment: Inpatient Hospital 

The insurer denied the inpatient stay. The determination is upheld. 

The patient presented to the emergency department because of a sudden onset of the chest pain as well as shortness of breath that were accompanied by homicidal ideation. These symptoms started two hours before his presentation. The patient stated that he had intermittent midsternal chest pain for over two weeks. It was sharp in nature, 8/10 in severity, with radiation to the right side of the neck. The pain was aggravated by physical exertion, but there were no alleviating factors reported. 

On the day of admission, the patient was walking on the street and thinking about stressful social issues happening in his life when he started to experience increasing midsternal chest pain and mild shortness of breath that were accompanied by nausea, sweating. At that time he started to have a homicidal ideation with no solid plan in place. This prompted him to call an ambulance, which brought him to the emergency department. 

A review of systems was obtained on admission. It was positive for chronic bilateral hand tingling and numbness. At the time of admission, the patient expressed an interest in talking to a psychiatrist. On the physical exam, the patient was afebrile, pulse rate was 93 beats per minute (bpm), respiratory rate 16, blood pressure 127/78, and oxygen saturation 96% on 2 liters (L) of oxygen via nasal cannula. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits. Lungs were clear to auscultation without wheezing, rales, or rhonchi. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The abdominal exam was benign. Peripheral pulses were within normal limits. The neuro exam was grossly intact.
Laboratory evaluation revealed that the white blood cell count was 4.7, hemoglobin 12.2, hematocrit 36.4, and platelets 136. Sodium was 143, potassium 4.4, chloride 107, bicarbonate 30, blood urea nitrogen (BUN) 21, and creatinine 1.53. A urinalysis was unremarkable. Arterial blood gas (ABG) was within normal limits. 

In the hospital, the patient was seen by a cardiologist who determined that patient's chest pain was likely related to gastritis. It was stated that acute coronary syndrome was ruled out. There was no stress test performed since the patient had a stress test done previously that demonstrated excellent exercise tolerance and negative myocardial perfusion images. 

In the hospital, the patient was seen by a psychiatrist who diagnosed the patient with adjustment disorder. The psychiatrist recommended continuing to optimize medical management. The psychiatrist suggested that the patient would benefit from psychotherapeutic services. There was no mention that the patient required inpatient psychiatric care. At issue is the medical necessity of an inpatient stay. 

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. This patient presented to the hospital with complaints of chest pain, mild nausea, mild shortness of breath, and homicidal ideations that were likely triggered by his stressful social issues. 

During the hospital stay, the patient was ruled out for acute coronary syndrome since his serial troponins remained normal. He was evaluated by the cardiology service and was not recommended any further cardiac evaluation while in the hospital. The chest discomfort was attributed to possible gastritis. The patient reported homicidal ideations but had no particular plan in mind. The patient was evaluated by psychiatry service and was recommended a continuation of treatment as an outpatient. There was no need for inpatient psychiatric services. 

At the time of admission, the patient had mild kidney insufficiency since his creatinine level was slightly higher than the baseline. This mild elevation of the creatinine level did not meet the definition of an acute kidney injury and normalized very quickly while in the hospital. Taking into consideration all of this information neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care. 

Care could have been provided at a lower level to rule out acute coronary syndrome and evaluate further for homicidal ideations. There was no evidence of acute coronary syndrome or any other serious reasons for chest pain. The patient did not require immediate inpatient treatment for homicidal ideations and had no particular plan. 
Mild elevation of the creatinine did not qualify for the definition of acute kidney injury and did not require admission to the hospital at the acute inpatient level of care.