Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest Pain.
Treatment  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

This is a patient with a past medical history significant for arthritis, bone fibrous dysplasia, paroxysmal hemicrania, and tobacco use disorder, who presented to the emergency department with complaints of substernal chest pain that was intermittent and had been occurring for one week.

The patient described the pain as squeezing, occasionally sharp.  It was associated with arm and leg pain and numbness.  The pain lasted for 15 - 25 seconds each time.  The patient reported multiple episodes of chest pain every day.  The review of systems was negative for nausea, vomiting, shortness of breath, diaphoresis, abdominal pain.  The patient complained of great cough times 2 weeks.  The rest of the review of systems was negative.

When seen by the admitting physician the patient was afebrile.  His pulse rate was 68 beats per minute (bpm), respiratory rate 18, blood pressure 119/73, and oxygen saturation 98% on room air.

The sodium was 141, potassium 4.2, chloride 104, bicarbonate 26, blood urea nitrogen (BUN) 11, creatinine 1.1, and glucose 101.  Lipase was 36.  The troponin was within normal limits.  A venous blood gas did not demonstrate significant abnormalities.  The white blood cell count was 8.5, hemoglobin 15.9, hematocrit 49.0, and platelets 227.  A chest x-ray showed no acute abnormalities.

The patient was admitted to the hospital with chest pain to rule out acute coronary syndrome.  In the hospital, the patient underwent a nuclear stress test, which was negative.  The patient had preserved left ventricular systolic function.  While in the hospital, his symptoms resolved.  It was suggested that those symptoms could be related to cervical radiculopathy.  The patient was discharged home in stable clinical condition.  At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary for this patient.  There was no clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care than admission to an inpatient level of care.  The patient presented to the hospital with complaints of chest pain, which was atypical based on the history and evaluation.  The physical exam, results of the laboratory studies, and diagnostic tests were reassuring and did not point toward the presence of serious medical problems requiring admission at the acute inpatient level of care.  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.

Based on the Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 23rd Edition criteria for Chest Pain, 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 demonstrated that the patient had none of the circumstances listed in the criteria.