Appeal type: Medical necessity
Decision: Upheld

Chest pain
Inpatient stay

The patient has a past medical history significant for asthma, hypertension, chronic kidney disease, congestive heart failure, peripheral vascular disease, coronary artery disease, myocardial infarction, and previous history of intravenous drug use who presented to the emergency department with complaints of intermittent substernal chest pain that the patient described as tightness. It lasted for a few seconds and resolved without any intervention, was non-radiating. In addition, the patient complained of worsening exertional dyspnea. At the time when seen in the emergency department, patient denied chest pain, shortness of breath, or palpitations. The review of systems was also positive for worsening dyspnea on exertion. Tenderness to palpation over the sternum was noted. The patient had bilateral pitting edema in the lower extremities. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that sodium was 143, potassium 3.7, chloride 108, bicarbonate 27, blood urea nitrogen (BUN) 12, creatinine 1.6, glucose 118. alanine aminotransferase (ALT) was 26, aspartate aminotransferase (AST) 47. Troponin was normal. The white blood cell count was 5.2, hemoglobin 12.4, hematocrit 36.9, platelets 200.
Urine drug screen came back positive for cocaine and the patient admitted to using cocaine just hours before the admission. The electrocardiogram (EKG) demonstrated normal sinus rhythm, Q waves were present in leads V1-2, otherwise, no changes. Chest x-ray demonstrated findings consistent with chronic obstructive pulmonary disease (COPD). There was no evidence of acute lung consolidation, pulmonary edema, or pleural effusions. The patient was admitted to the hospital with a diagnosis of chest pain. It was mentioned in the history and physical exam note that 2 sets of troponin were normal. The patient was admitted to the hospital to rule out acute coronary syndrome and received treatment with Aspirin, statin, and Nitroglycerin.
During the hospital stay the patient underwent an echocardiogram, which demonstrated normal ejection fraction. Cardiology consultation was obtained. The health plan determination of medical necessity is upheld in whole. There is no doubt that the patient had risk factors for the acute coronary syndrome, but the presentation was not consistent with acute myocardial infarction or unstable angina. In fact, the patient had reproducible chest pain and normal troponins.
The patient was evaluated by a cardiologist and diagnosed with atypical chest pain, which could have been triggered by cocaine use. Considering the patient's previous medical history, an admission at a lower level of care to rule out acute coronary syndrome was appropriate. At the same time, the severity of the patient's condition and the complexity of the medical services provided did not justify an acute inpatient level of care.
The patient's lower extremity swelling could have been related to the use of calcium channel blockers, and this was addressed during the hospital stay. The patient's complaint about lower extremity pain associated with walking was also assessed by the cardiology service, and it was determined that the patient did not require any intervention during this hospitalization. The patient received counseling on the risks of cocaine use, also concomitant use of cocaine and beta-blockers, including the risk of coronary artery spasm or progression of an ischemic cardiac event and even sudden death. The patient received evaluation and treatment that were appropriate for the condition, but those services could have been provided at a lower level of care.