Appeal type: Medical necessity
Decision: Upheld

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


This is a female patient who presented to the emergency department complaining of three days of chest pain. Her medical history was remarkable for hypertension, type 2 diabetes, hyperlipidemia, alcohol use disorder, polysubstance abuse, hypertrophic cardiomyopathy, anemia and recently diagnosed Heliobacter pylori gastritis. She admitted due to noncompliance with her prescribed medical regimen. Her blood pressure was 192/88 millimeters of mercury (mmHg) with a heart rate of 91 beats/minute. Her respiratory rate was 16 breaths/minute with a room air oxygen saturation of 95 percent (%). On physical exam, she was obese and somnolent but easily arousable. Her pulmonary exam was remarkable for bibasilar rales. She had a systolic murmur and 1 plus (+) lower extremity edema. There was chest wall tenderness to palpation. An electrocardiogram showed sinus rhythm with anterolateral T wave inversion. Her serum troponin level was normal and remained normal when re-measured. Her N terminal pro brain (or B-type) natriuretic peptide (BNP) level was 675 picograms per milliliter (pg/ml). A chest x-ray showed cardiomegaly and interstitial edema. A urine drug screen was positive for cocaine. The patient was treated with intravenous furosemide and oral hydralazine and admitted to the hospital for management of decompensated heart failure. Her previously prescribed antihypertensive regimen was started. Furosemide was continued. Her chest pain was attributed to gastritis. Clonidine was added to her regimen and she was discharged. At issue is the medical necessity for an inpatient admission.

Based on the documentation provided, an inpatient level of care was not medically necessary.

This patient presented with chest pain and was found to be in decompensated heart failure. Regarding her heart failure, she was hemodynamically stable and did not have high risk features such as a systolic blood pressure less than (<) 100 mmHg; electrocardiographic changes consistent with ischemia; cardiac troponin elevation; serum creatinine level greater than (>) 3 milligrams per deciliter (mg/dL); or significant hyponatremia (< 135 mEq/L). Based on her Emergency Heart Failure Mortality Risk Grade score her 7-day mortality risk was low. She improved with intravenous furosemide. In stable heart failure patients, such as this patient, without high-risk features, studies have shown that a lower level of care is safe and effective, with similar outcomes, including readmission, repeat emergency department visits and 30 day mortality, when compared to those treated as inpatients. Thus, in this instance, a lower level of care would have been sufficient for management of her heart failure; an inpatient admission was not medically necessary.
Regarding the patient's chest pain: She was hemodynamically stable, with normal serum troponin levels, and no acute electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The etiology of her pain was found to be non-cardiac. The care this patient received for her chest pain did not require an inpatient admission and could have been provided under 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 Evaluation and Diagnosis of Chest Pain and the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.