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 complaining of one day of intermittent chest pain and dyspnea. His medical history was remarkable for coronary artery disease, multiple percutaneous coronary interventions and bypass graft surgery, heart failure with reduced ejection fraction (36%), hypertension, hyperlipidemia, atrial fibrillation, human immunodeficiency virus (HIV) infection and cigarette smoking. He reported having had a fever and upper respiratory symptoms in late December that had since resolved. In the emergency department his blood pressure was 132/76 millimeters of mercury (mmHg) with a heart rate of 54 beats/minute. His respiratory rate was 16 breaths/minute with a room air oxygen saturation of 100%. He was afebrile. His physical exam was unremarkable. An electrocardiogram showed sinus bradycardia at a rate of 50 beats/minute without acute changes. His serum troponin level was normal. His brain (or B-type) natriuretic peptide (BNP) level was 221 picograms per milliliter (pg/ml). A chest x-ray showed pulmonary vascular congestion and possible small pleural effusion. The patient was admitted to the hospital for cardiac catheterization for possible acute coronary syndrome. A test for coronavirus 2019 (COVID-19) was positive; however, an infectious disease consultant opined that this was likely due to "dead virus" and that no treatment was necessary. An echocardiogram showed a left ventricular ejection fraction of 40-45%. Cardiac catheterization showed an occluded first obtuse marginal artery after the insertion of a patent bypass graft that was treated with a stent. There was a patent left internal mammary artery to the left anterior descending artery. The procedure was uncomplicated. The patient was discharged. The medical necessity for an inpatient admission is under review.

Based on the documentation provided an inpatient level of care was not medically necessary.
This patient, with known coronary artery disease, presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. Based on his HEART score [history, electrocardiogram (EKG), age, risk factors, and troponin] , he was at intermediate risk for major adverse events. He did not require intensive monitoring or continuous infusion and titration of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with current guidelines, including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
The patient underwent an uncomplicated percutaneous coronary intervention (PCI). Inpatient care after this procedure was not medically necessary. Per the 2018 expert consensus document from the Society for Cardiovascular Angiography and Interventions, in the absence of acute ST segment elevation myocardial infarction, inpatient care following PCI is generally unnecessary.