Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain, Muscle Spasms
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay as not medically necessary.
The determination is upheld.


The patient has a past medical history significant for hyperlipidemia who presented to the emergency department with the sudden onset of chest pain. The pain was located in the left side of the chest and radiated to the neck and posterior part of the left shoulder. The patient described the pain as "ripping open," severe. The pain began while the patient was resting and getting ready to sleep. He denied any physical exertion or recent injuries that caused the pain. He denied changes in his diet or any prior similar episodes.
The review of systems was negative for recent illness, headache, vision changes, speech difficulties, muscle weakness, sensory problems, or any other symptoms. The patient stated that these episodes of chest pain were associated with shortness of breath because he could not take a deep breath at the time.
The admitting physician stated that in the emergency department the patient's vital signs were stable. His laboratory results were unremarkable, including a negative troponin.
The chest x-ray performed in the emergency department did not demonstrate any evidence of pneumothorax, widened mediastinum, consolidation, or effusion. The electrocardiogram (EKG) demonstrated normal sinus rhythm without ST elevations or depressions.
The vital signs were a temperature of 98.3 degrees Fahrenheit (F), blood pressure 147/84, pulse rate 80 beats per minute, respiratory rate 18 breaths/min, and oxygen saturation 98% on room air.
When the patient was seen by the admitting physician, he was in mild distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits. 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, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The rest of the physical exam was unremarkable.
The laboratory evaluation revealed that his white blood cell count was 10.0, hemoglobin 13.5, hematocrit 39.8, and platelets 291. The sodium was 141, potassium 4.2, chloride 104, bicarbonate 23, blood urea nitrogen (BUN) 14, creatinine 0.91, and glucose 114. Troponin and brain (or B-type) natriuretic peptide (BNP) were within normal limits.
The patient was admitted to the hospital with a diagnosis of chest pain. The differential diagnosis included musculoskeletal cramping versus radiculopathy versus acute coronary syndrome. The admitting physician stated that the concerning finding was left upper extremity weakness and numbness. The pain was non-exertional.
In the hospital, the patient was seen by a neurologist. The main finding on the neurologic exam was a weakness in the right triceps. The differential diagnosis included brachial plexopathy versus left shoulder arthropathy or radiculopathy.
A magnetic resonance imaging (MRI) of the cervical spine was performed and reviewed by the neurologist. The neurologist also recommended an MRI of the shoulder and brachial plexus, which according to their recommendations could have been done as an outpatient. The patient also required physical and occupational therapy evaluation. The cardiac workup that was performed in the hospital was negative for acute coronary syndrome.
The MRI of the cervical spine revealed degenerative changes, disc dislocation, and mild narrowing of the spinal canal. This was evaluated by neurosurgery and there was no indication for surgical intervention during this admission.
Since his clinical condition significantly improved, he was discharged from the hospital. 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.
Based on accepted standards of care, admission at the acute inpatient level of care is required in cases of chest pain and hemodynamic instability, respiratory distress, chest pain, indicative of serious diagnosis other than coronary artery disease, also in cases of angina or myocardial infarction. The review of the medical records clearly demonstrated that the patient had none of the circumstances listed above. The patient's symptoms were most likely related to a musculoskeletal origin versus peripheral nerve disease.
The patient did not require any interventions performed in the hospital that would justify admission at the acute inpatient level of care.
His hospital admission was very short. During the entire admission, the patient remained afebrile and hemodynamically stable. The results of the laboratory studies were unrevealing.
Taking into consideration all of this information, there is not overwhelming evidence that either the severity of the patient's condition or the complexity of the services provided rose to the acute inpatient level of care. Care could have been provided at a lower level to rule out acute coronary syndrome and other potentially serious reasons for the patient's symptoms, to ensure adequate pain control, and to formulate a plan of treatment after the discharge.
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. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.