Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

No, inpatient level of care was not medically necessary.

This female with multiple medical problems presented to ED with chief complaint of palpitations while at work.  Comorbidities include diabetes, hypertension, atrial fibrillation, coronary artery disease (CAD), pulmonary embolism and morbid obesity.  In the ED, she denied chest pain, but endorsed palpitations, dyspnea, and weakness.  The patient was described as resting normally in the ER.  Exam was unremarkable.  Vital signs stable, oxygen saturation was normal, electrocardiogram (EKG) did not show acute changes and chest x-ray (CXR) was normal.  Creatinine was elevated, so the patient received intravenous fluids (IVF) and resumed her medications.  She was evaluated in the morning and denied chest pain, palpitations, and was described as euvolemic without congestive heart failure (CHF).  The creatinine had improved.  Nurses' notes confirm absence of symptoms as well as no arrhythmias seen.  Decision was made to observe one more day looking for possible atrial fibrillation.  Echocardiogram was determined to be unnecessary, as she had a recent one.  She was discharged with diagnosis of coronary artery disease without angina.  Acute bronchitis was the primary diagnosis. 

The determination of appropriate 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; and highlighted in the orders for care. 

In this case, the symptoms were atypical for acute coronary syndrome (ACS) or paroxysmal (PAF), and unlikely to be representative of acute coronary syndrome. Exam (blood pressure normalized) and cardiac findings were normal.  Biomarkers and EKG showed no evidence of acute ischemia.  CXR was normal.  Echocardiogram was not requested.  The physicians' treatment did not reflect any serious concern about the patient's cardiac condition.  Orders did not include medical therapy for ACS, such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG).   

The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care.  No documentation of 'severe chest pain'.  She received aspirin (ASA) and IVF in the ED.  The only cardiac care provided was telemetry, frequently performed in a lower level of care.  The patient was admitted for monitoring, and subsequent tests and therapy did not require an inpatient level of care.  There was no complex care that required inpatient care.  She received IVF to correct her elevated creatinine.  This patient had no evidence of CAD.  In fact, all tests showed absence of ischemia or symptomatic arrhythmia.  While there is always a potential for an adverse event (and in this case a very low probability), one did not happen, and no actual treatment was added.  No evidence was documented in the appeal letter that this care could not have been done in an outpatient facility.

Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS present.  Patient was chest pain free and no diagnosis of angina was present.  There was no hemodynamic instability.  All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care.  Thus, inpatient level of care was medically unnecessary.

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