Appeal type: Medical necessity
Decision: Upheld

Chest Pain
Inpatient Hospital

The patient is a male who presented to the emergency department (ED)  by ambulance with chest pain. The patient reported intermittent chest pain and shortness of breath associated with exertion. The patient suffered from these symptoms for several days and they were progressing. He was seen by his cardiologist in the office and sent to ED. The patient has history of coronary artery disease (CAD), post left anterior descending (LAD) percutaneous coronary intervention (PCI) with diagonal disease.

The patient was evaluated in ED. His vital signs were abnormal with heart rate 82 beats per minute (BPM). Blood pressure (BP) and oxygen (O2) saturation were normal. Physical examination was unremarkable, beside worsening lower extremity (LE) edema. His labs were unremarkable, but His brain natriuretic peptide (BNP) was elevated to 695. His chest x-ray (CXR) was normal. His heart rate (HR) with another set of vitals was documented to be 47 BPM. His electrocardiogram (ECG) was interpreted as accelerated junctional rhythm.

The patient underwent echocardiogram in ED, there was no pericardial effusion. The patient was seen in consultation by the cardiologist who indicated that his ECG abnormalities are new, and recommended evaluation for ischemia. The patient was admitted to the telemetry. His troponin was done in series. It was 12 and repeated 11. He was started on intravenous (IV) Lasix. The patient noted to be in sinus bradycardia.
The patient underwent cardiac catheterization. His coronary anatomy was described as follows: left main (LM) 20% ostial, LAD 40% in stent stenosis, right coronary artery (RCA) proximal 40% stenosis and right posterolateral (RPL) 50% stenosis.
The patient was discharged home in stable condition. The subject under review is the medical necessity for an inpatient stay.

The health plan's determination is upheld.

The requested health service/treatment of inpatient stay not medically necessary for this patient.The patient was complaining of chest pain and dyspnea. However, there was no supporting evidence of unstable angina or congestive heart failure.  His ECG did not reveal ST or T changes. His troponin was unremarkable, not suggestive of acute coronary syndrome (ACS). His coronary angiography revealed moderate disease, not correlating with patient's chest pain.  The patient was complaining of dyspnea and noted worsening LE edema. However, LE edema could be due to venous insufficiency, and not necessarily an indication for heart failure. His BNP was elevated, but that could be close to his baseline. His CXR was clear. He was not diagnosed with congestive heart failure.

The patient had episode of accelerated junctional rhythm. Most of the time in the hospital he was in sinus bradycardia, and that was stable, without indications that he has unstable cardiac rhythm. There were no actions taken toward his bradycardia.
Based on all above, the patient did not have unstable angina, congestive heart failure exacerbation or unstable cardiac arrhythmia.
The care for this patient could have been provided under a lower level of care status. Inpatient level of care was not medically necessary.