Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital stay. 

The insurer denied: Inpatient Hospital stay.  The denial is upheld in whole.

The patient is a female with a past medical history significant for a recent tibial fracture who presented to the hospital with sudden onset of chest pain while sitting on the sofa. The patient described chest pain as burning and associated with palpitations, shortness of breath, fatigue, mild dizziness. The patient stated that her whole body became numb. At the same time, she denied nausea, vomiting, syncope. Her symptoms lasted for three hours. While at home, the patient checked her blood pressure, which at that time was 149/80. She decided to come to the emergency department for further evaluation.
When seen by the admitting physician the patient was in no acute distress. She was not lethargic. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The gastrointestinal (GI) exam was within normal limits. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that serum sodium was 139, potassium was 3.9, chloride was 100, bicarbonate was 19, blood urea nitrogen (BUN) was 16.6, creatinine was 0.59, glucose was 119. White blood cell count was 14.81, hemoglobin was 13.1, hematocrit was 37.8, and platelets were 484. Troponin was normal.

Computed tomography (CT) angiogram of the chest showed no evidence of pulmonary embolism. There were 7 millimeter (mm) right upper lobe and 4 mm right middle lobe nodules, also bibasilar subsegmental atelectasis.

The patient was admitted to the hospital to rule out acute coronary syndrome. While in the hospital, the patient was seen by a cardiologist who recommended checking cardiac enzymes and obtaining serial electrocardiograms (EKGs), also checking lipid panel, hemoglobin A1c, and obtaining a transthoracic echocardiogram.

The cardiologist stated that no inpatient ischemic workup was required and recommended outpatient follow-up.

During the hospital stay, the patient remained in stable clinical condition. Her symptoms resolved, and the patient was discharged home in satisfactory condition. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld. 

The review of the medical records clearly demonstrated that the patient's chest pain was not associated with hemodynamic instability, respiratory distress. Based on the evaluation performed in the hospital, there were no indications that the chest pain was indicative of serious diagnoses such as acute coronary syndrome, aortic dissection, aortic aneurysm, pulmonary embolism, or pneumothorax. The patient's symptoms were short-lived. She was evaluated by a cardiologist who did not feel that the patient even required ischemia workup in the hospital.

There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care status.  Overall, she remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.