Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Chest Pain.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay. 
The health plan's determination is upheld.

The patient is a female who initially presented to the emergency department with concerns for atypical chest pain and then alcohol detoxification. Pertinent history included alcohol use disorder, polysubstance abuse, bipolar disorder, and homelessness. Initial vital signs revealed a temperature of 99.1F (Fahrenheit), a heart rate (HR) of 93 beats per minute (bpm), a blood pressure (BP) of 113/77 millimeters of mercury (mmHg), a respiratory rate (RR) of 20/minute, and a peripheral capillary oxygen saturation (SpO2) of 97% on room air. Initial examination documented the patient as alert and oriented. An electrocardiogram (EKG) revealed no acute ischemic changes but did note a QTc of 517 ms (millisecond). Initial laboratory testing revealed a white blood cell count (WBC) of 4.4, a hemoglobin of 13.3, platelets of 211, an ethanol of 0.8 (within normal limits), a sodium of 138, a potassium of 4.4, a blood urea nitrogen (BUN) of 14, a creatinine of 1.0, a carbon dioxide (CO2) of 20, and an Anion gap of 11. High sensitivity Troponin was negative. Urine drug screen was positive for cocaine, benzodiazepines, and amphetamines. A urinalysis was unremarkable. The patient was medically cleared for chest pain by the emergency department physician, however, then alcohol detoxication was addressed. A repeat electrocardiogram revealed a 529 ms QTc. Due this prolonged QTc (duration of QT interval) (QT= time taken for depolarization and repolarization), the patient was felt to not be medically stable. The patient was placed in the hospital under the medicine team. The treatment plan included serial cardiac enzymes, telemetry, Clinical Institute Withdrawal Assessment (CIWA) (score assessed at 5), and Lorazepam per assessment. No overnight events were reported. Chest pain had improved. Acute coronary syndrome was ruled out. Hemodynamics were stable. Nursing noted the patient was ambulating and tolerating a solid diet without issue. The CIWA score was noted to be a 4. Detoxification disposition was pursued. The patient was discharged.
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is upheld, in whole.

No. Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission.

In this particular situation, the applicable aforementioned diagnostic testing was performed and was essentially unremarkable. The patient had a history of polysubstance abuse, psychiatric disorders, and alcohol use disorder who presented with chest pain and a request for alcohol detoxification. The emergency department physician documented atypical chest pain. The initial evaluation did not reveal significant findings suggestive of an emergent condition. There was evidence of a prolonged QTc, but no arrhythmias were noted on EKG or telemetry. No CIWA scores over 5 were documented and the patient had no documented history of seizures or delirium tremens. Following observation care, the patient was hemodynamically stable, ambulating, tolerating a diet, and acute coronary syndrome had been ruled out. No other issues or complications were documented.
Moreover, clinical indications for admission to inpatient care were not met. The patient did not have pulmonary edema most likely due to ischemia, new or worsening mitral regurgitation murmur, third heart sound, new or worsening rales, hypotension, bradycardia, tachycardia, transient ST-segment deviation of 0.5 mm (millimeters) or more on EKG, recurrent or refractory ischemic symptoms despite treatment, left ventricular ejection fraction less than 40%, intermediate or high-risk ischemia findings on noninvasive testing, evidence of a myocardial infarction, hemodynamic instability, or respiratory distress.[2][3]