Appeal type: Medical necessity
Decision: Upheld

Chest Pain
Inpatient Hospital

The patient is a female who presented to the emergency department (ED) with right sided shoulder and chest pain. The chest pain was associated with diaphoresis and shortness of breath., as well as dry cough.
The patient has past medical history for diabetes mellitus (DM), anxiety, hyperlipidemia and she has history of motor vehicle accident (MVA) two years ago. She suffered tear of her right shoulder ligaments, was recommended surgery but did not undergo surgery. The patient developed right sided chest pain and right shoulder pain 4 days prior to presentation.
The patient has chronic neuropathy of both feet. She suffers from anxiety and is on benzodiazepines.
In ED, she was evaluated. Her vital signs were stable. her physical examination was unremarkable. Her blood glucose was 400. Her white blood cell (WBC) count was 12.0, lactate was 5.6, and triglycerides (TGL) were 390. Her HgA1C was 10.7%. Her troponin T was less than 6, normal. Her anion gap was 20, but repeated was 15. Arterial blood gas (ABG) did not reveal acidosis.
She was not compliant with her diet and medications.
Her electrocardiogram (ECG) was unremarkable and her chest x-ray (CXR) was clear.
The patient was admitted to telemetry unit for chest pain, suspected musculoskeletal. Her echocardiogram was normal. Her computed tomography (CT) angiogram of the chest was negative for pulmonary emboli. Her regadenoson stress nuclear test revealed left ventricular ejection fraction (LVEF) greater than (>)70%. There were mild to moderate defects in the mid to distal anterior, apical and basal septal walls that are mostly fixed, partially correct with prone imaging, and demonstrate preserved wall motion suggestive of attenuation artifact.
She was given IV fluids. She was treated for pain with Lidocaine patch and pantoprazole. The patient was consulted by endocrinologist, who readjusted her insulin regimen and insulin sliding scale. The patient's condition improved. She was discharged home.
The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. The patient presented with atypical chest pain and with underlying history of shoulder trauma. Her chest pain was suspected to be not cardiac and due to her shoulder problem from the beginning. However, she underwent appropriate evaluation due to presence of uncontrolled diabetes mellitus. Her ischemic work up was negative, including stress test and echo. Pulmonary embolism was ruled out. The patient had very high blood sugar upon presentation. However, she was managed by subcutaneous insulin injections.
The patient had mildly elevated WBC and she had elevated lactic acid and anion gap. However, after intravenous fluids (IVF) were given, her anion gap improved. WBC went down. The patient was not evaluated or treated for any infection.
Therefore, above findings don't have clinical significance and are not  enough to support inpatient admission, the patient could have been managed at a lower level of care status.