Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and shortness of breath
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The Inpatient admission was not medically necessary, as inpatient level of care was neither indicated nor provided.

The patient is a female. She was admitted to rule out ACS (acute coronary syndrome). Her presentation included chest pain and dyspnea for two days. She also had weakness for five days. ASA (aspirin) gave some relief. Her past medical history showed diabetes, hypertension, morbid obesity, GERD (gastroesophageal reflux disease) and sciatica. One year prior, she had similar presentation, with Cath showing no significant disease and stress test normal. 

This visit included enzymes negative x 3, no acute EKG (electrocardiogram) changes.  She received IVF (intravenous fluids) and IV pain medications. Nuclear exam revealed LV (left ventricle) dysfunction with no evidence of ischemia (no reversible defects). She was discharged with diagnoses of atypical chest pain, non cardiac. 

The patient had a low probability of having significant CAD (coronary artery disease) or need for an urgent intervention. 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 (ACS). Her exam and cardiac findings were normal. Biomarkers and EKG (electrocardiogram) showed no evidence of acute ischemia. CXR (chest x-ray) was normal.  Nuclear scan was negative for CAD, and measurement of ejection fraction on nuclear studies is often inconsistent. The treating physicians also did not need to follow up on that finding. The physicians' treatment did not reflect any serious concern about the patient's cardiac condition.  Orders did not include medical therapy for ACS, such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV NTG (nitroglycerin).  
 
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 level of care in this patient's care post catheterization. This patient had no evidence of CAD. In fact, all tests showed absence of ischemia.  While there was always a potential for an adverse event, 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 of the testing and therapy that were provided would have been appropriate, safe and guidelines-consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.

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