Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment: Inpatient Stay.
The insurer denied: Inpatient Stay.
The denial is: Upheld.

The patient is a female with a history of lung cancer post lobectomy, receiving cisplatin-based chemotherapy, who presented to the hospital with left-sided chest pain and dizziness. The patient also had nausea, vomiting, and weakness. The chest pain symptoms have been present for a few months; she was evaluated with an outpatient Holter monitor and noted to have intermittent tachycardia. On the day of arrival, the patient experienced slurred speech and confusion, as reported by the husband.

Assessment in the emergency department (ED) included head computed tomography (CT) which showed no acute intracranial abnormalities. The patient's exam showed an alert and oriented x3 person with no jugular vein distention (JVD) and normal bilateral chest expansion with no wheezes. The abdomen was soft. Distal pulses were preserved.
Laboratory studies included a normal cardiac troponin. The chemistry panel was fairly unremarkable, and so were the liver function tests (LFTs). The twelve-lead electrocardiogram (EKG) showed normal sinus rhythm. CT of the chest showed small right pleural effusions and subcutaneous emphysema of the right breast.
The medical team was asked to admit the patient to the hospital for chest pain and dizziness. They ordered an echocardiogram and brain magnetic resonance imaging (MRI) and admitted the patient to the hospital.

The inpatient stay was not medically necessary. Based on the provided documentation, the patient presents to the hospital with vague symptoms of generalized weakness, nausea and vomiting post-chemotherapy, non-exertional chest pain, and questionably slurred speech. 2 parallel work-ups were initiated in the hospital to ensure stroke and acute coronary syndrome were ruled out. Imaging studies, per stroke protocol, were negative for an acute cerebrovascular accident (CVA), and the patient had a National Institutes of Health (NIH) stroke scale of 0. Therefore, the stroke work-up was completed within the observation timeframe. From an acute coronary standpoint, the patient had a recent outpatient echocardiogram and a Holter monitor for similar complaints without major abnormalities. Cardiac troponin was normal, and so was the EKG. The patient stress test was suboptimal and questionably abnormal. Therefore, a definitive rule-out was sought through left heart catheterization, showing no obstructive disease. There were significant delays in obtaining the stress test and the left heart catheterization, prolonging the patient's stay beyond the typical observation limit. However, the hospital stay duration was not directly related to the patient's clinical status. The patient was described as stable, without complaints of additional angina, ambulating, conversational, and with stable vital signs and labs. There were no clinical barriers to performing a cardiac stress test the following day after admission.
In summary, the entire work-up could have been accomplished under a lower level of care status. The patient's testing results were unremarkable. There is no indication an inpatient stay.