Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is upheld. 

The patient is a male who presented to the emergency department after an episode of chest pain and dyspnea that had lasted for two days. He also reported nasal congestion and myalgias. He had no chest pain at the time of presentation. His medical history was remarkable for a long cigarette smoking history. His blood pressure was 115/80 millimeters of mercury (mmHg) with a heart rate of 131 beats/minute. His respiratory rate was 17/minute with a room air oxygen saturation of 94%. His physical exam was unremarkable. An electrocardiogram showed sinus tachycardia without acute changes. His serum troponin level was .07 nanograms/milliliter (ng/ml); when re-measured it was .06 ng/ml. His serum creatinine was 2 mg/dl. Chest X-ray showed no acute pathology. His BNP level was normal. The patient was treated with intravenous fluid, aspirin, Plavix, heparin, a statin and metoprolol. He was admitted to the hospital. Intravenous hydration was continued. A third troponin level was .03 ng/ml. His serum creatinine level was 1.0 milligrams per deciliter (mg/dl). The progress note from that date indicated that acute coronary syndrome had been ruled out and that a stress test would be performed. An echocardiogram showed normal left ventricular systolic function and no significant valve disease. The stress test with perfusion imaging showed no evidence of ischemia. The patient was discharged. Medical necessity for an inpatient stay is at issue. 

The health plan's determination is upheld. 

Based on the documentation provided an inpatient stay was not medically necessary. This patient presented with chest pain that was thought to possibly represent acute coronary syndrome (ACS). Thus, monitoring until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable without acute electrocardiographic changes. His serum troponin level was not diagnostic for myocardial infarction. He did not require intensive monitoring or continuous infusion of cardioactive medication. No urgent intervention for ACS was deemed necessary. The care this patient received for his chest pain did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be both 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 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes. 

Upon presentation the patient was found to have an elevated serum creatinine level. This was not associated with electrolyte perturbations or significant acid/base disturbance. His creatinine normalized after intravenous fluid administration, suggesting that the etiology was volume depletion. An inpatient stay was not required for treatment of this patient's elevated creatinine level.