Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history significant for anxiety and substance abuse who presented to the emergency department with complaints of chest pain. Reportedly, he was admitted to a different hospital one month before the presentation, where he was ruled out for acute coronary syndrome. He described the chest pain as mid-sternal, sharp, non-radiating without modifying factors. The pain was intermittent and occurred every two-three hours and lasted for 30 seconds. The patient also complained of some chest tightness associated with difficulties breathing. The patient stated that his symptoms could have been related to not taking clonazepam.
At the time of admission, the patient was afebrile. His blood pressure was 139/82, pulse rate 65 beats per minute (bpm), respiratory rate 18, blood pressure 139/82, and oxygen saturation 98% on room air.
The patient appeared undernourished and anxious. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, nontender to palpation, with normal bowel sounds, without guarding or rebound. The neurological exam was unremarkable.
Laboratory evaluation revealed that the serum sodium was 138, potassium 3.7, chloride 98, bicarbonate 30.5, blood urea nitrogen (BUN) 9, creatinine 0.8, and glucose 91.
The white blood cell count was 4.46, hemoglobin 12.3, hematocrit 36.5, and platelets 248. The troponin was normal and creatine phosphokinase (CPK) was normal.
The patient tested positive for coronavirus disease 2019 (COVID-19). A chest x-ray demonstrated small left basilar discord atelectasis.
The patient was admitted to the hospital with a diagnosis of chest pain, COVID-19, anxiety disorder, and a history of polysubstance abuse. The patient was admitted to rule out acute coronary syndrome and to monitor oxygen saturation considering his COVID-19 infection. The treatment with clonazepam was resumed. During the hospital stay, the patient remained afebrile and hemodynamically stable.
He was ruled out for acute coronary syndrome. It was also noted that the patient's COVID -19 immunoglobulin (Ig) G antibodies were positive.
In the hospital, the patient remained afebrile and hemodynamically stable. He was transitioned to outpatient 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. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care.
He was admitted to the hospital with complaints of chest pain and tightness and was ruled out for acute coronary syndrome. There was no need for any invasive procedures or treatments requiring admission at the acute inpatient level of care.
Even though the patient tested positive for COVID-19, there was no evidence of hypoxemia, acute respiratory failure, or any other complications requiring admission at the acute inpatient level of care. Taking into consideration all of this information, care could have been provided at a lower level than inpatient primarily to rule out acute coronary syndrome or any other serious conditions contributing to his symptoms and to observe for signs of respiratory failure and hypoxemia in the setting of a positive COVID-19 infection. Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.