Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department (ED) with the sudden onset of chest pain, tightness associated with diaphoresis and shortness of breath followed by a syncopal episode with him passing out on the floor. The patient was practicing his martial art stands before the onset of pain followed by syncope. The patient was not sure how long he was on the floor, but when he awoke, he was able to ambulate and noticed swelling to the left side of his face. 

The patient also had intermittent abdominal cramping pain that started 1 year prior and progressively worsened. The patient had been seen by his primary care physician (PCP) one day prior to presentation to the ED, and he was hypertensive. He had recently suffered from coronavirus disease (COVID) and was hospitalized for a couple of weeks. His past medical history was significant for restless leg syndrome. The patient also had diabetes mellitus (DM), hyperlipidemia and tobacco abuse disorder. He, however, was not on any medications. He had recently been diagnosed with an elevated blood pressure (BP). The patient suffered from heartburn frequently, but his chest pain this time was different. 

His physical examination revealed that he had restless arms and legs. His lungs were clear, heart was regular. abdomen was soft, nontender and neurologically, he was intact. Urine was positive for cocaine. A head computed tomography (CT) scan revealed non-specific calcifications with no evidence of an acute intracranial hemorrhage or territorial infarction. Computed tomography angiography (CTA) of the chest was negative for a pulmonary embolism (PE). A chest x-ray (CXR) revealed a possible early or resolving consolidation at the left lung base. 
An electrocardiogram (ECG) revealed normal sinus rhythm with left anterior fascicular block. The patient was treated with an intravenous fluid (IVF) bolus, normal saline (NS), aspirin 325 milligrams (mg) and pramipexole 1.5 milligrams (mg). 

The patient was consulted by cardiology who opined that the patient presented with chest tightness along with diaphoresis and shortness of breath followed by a syncopal episode earlier this morning, suggestive of underlying coronary artery disease (CAD), plan for cardiac catheterization. The patient was admitted to the hospital with diagnosis of chest pain, likely secondary to cocaine use, rule out acute coronary syndrome (ACS).
The cardiologist reported that the patient was fidgety, tested positive for cocaine, reported that he took cocaine 2 days before presentation and had been using cocaine on a consistent basis before presenting to the hospital; cardiac enzymes were negative and the electrocardiogram (ECG) was without evidence of ischemia. They recommended to defer cardiac catheterization at present; presentation related to the cocaine use. They recommended an outpatient ischemic work up including a stress test. In the discharge summary, the patient stated that he felt fine and did not have any symptoms. The patient refused cardiac catheterization and denied drug use. The patient was discharged home. At issue is the medical necessity of an inpatient stay. 

The requested health service/treatment of inpatient stay was not medically necessary for this patient. The patient presented with syncope and chest pain. His vital signs, physical examination and cardiac enzymes, ECG and CT scan of the chest were unremarkable. The patient was observed on a monitor for 24 hours and he remained stable. His serial cardiac enzymes were normal, his ECG did not have any ischemic changes, and the rest of his lab results were unremarkable. A CXR suggested a resolving infiltrate, but clinically there was no evidence of pneumonia and he was not treated for pneumonia. 

The patient had evidence of cocaine exposure. Cocaine could cause serious cardiac complications, including CAD, myocardial infarction (MI) and cardiac arrhythmias. However, this patient did not have any evidence of an acute MI or cardiac arrhythmias or cardiomyopathy. He was discharged home next day in stable condition. An inpatient level of care was not medically necessary. 

Per the first reference: "Long-term cocaine use, as well as acute cocaine use, is associated with adverse cardiovascular consequences, including arrhythmias, angina, myocardial infarction, heart failure, and other conditions. Over the long term, cocaine can result in structural changes to the heart such as increased left-ventricular mass and decreased left-ventricular end-diastolic volume. Patients arriving with cocaine-associated cardiovascular complaints may not be forthcoming about their cocaine or polysubstance abuse or may be unresponsive. The role of beta-blockers, a first-line treatment for many forms of heart disease, is controversial in this population. Cocaine is a powerful sympathomimetic agent, and it was thought that beta-blockade would result in unopposed alpha-adrenergic stimulation and adverse consequences. A number of small, single-center, retrospective and observational studies suggest that beta-blockers may be safe, effective, and beneficial in this population. Further study is needed to clarify the role of beta-blockers in this population".