Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld. 

The patient is a male. He presented to the ED (emergency department) with sharp, left-sided chest pain and SOB (shortness of breath). He had history of atrial fibrillation on Eliquis, hyperlipidemia on Atorvastatin, BPH (benign prostatic hyperplasia) on Tamsulosin, and hypertension with low dose Metoprolol. He also had recent history of TURP (transurethral resection of prostate gland).

The patient was given NSAID (nonsteroidal anti-inflammatory drugs) in the ED (emergency department), IVF (intravenous fluids), and he was admitted to telemetry. EKG (electrocardiogram) showed atrial fibrillation with rate of 54. His enzymes were negative. He received Rocephin for hematuria, and Eliquis was restarted. CK (creatine kinase) was negative. Troponins were negative. BNP (brain natriuretic peptide) was normal. EKG (electrocardiogram) showed no evidence of ischemia. DVT (deep venous thrombosis) scan was normal.

The patient remained pain-free with no additional symptoms. No additional treatment was necessary. After an uneventful overnight stay, he was discharged with diagnosis of atypical chest pain.

No, the Inpatient admission was not medically necessary.
Inpatient level of care was neither indicated nor provided. 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. The patient's exam, BP (blood pressure) and cardiac findings were normal. Biomarkers and EKG (electrocardiogram) showed no evidence of acute ischemia. "Abnormal EKG [electrocardiogram]" was borderline. CXR (chest x-ray) was normal. The physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for ACS (acute coronary syndrome) such as IV (intravenous) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV (intravenous) NTG (nitroglycerin).

The letter of appeal was carefully considered, but it offered no evidence to support an 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 an inpatient level of care. 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 (acute coronary syndrome) present.

All testing and therapy that were provided would have been appropriate, safe and guidelines-consistent in a lower level of care. Thus, inpatient level of care was not medically necessary.

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