Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This adult female patient was hospitalized for chest pain. She presented to the emergency department for evaluation of worsening, constant retrosternal chest pain accompanied by dyspnea and wheezing. There was a pleuritic component that had worsened since she had been punched in the stomach by her boyfriend two days prior. On exam, vitals were remarkable for heart rate of 110, she was ill appearing, there were rales and 
wheezing in the lower lung fields, and one-plus pitting edema of the legs. Her past medical history includes chronic heart failure with heart failure with reduced ejection fraction (HFrEF) of 10-15 percent due to nonischemic cardiomyopathy; moderate-severe mitral regurgitation (MR) by echocardiogram 6 months ago; hypertension; hyperlipidemia; chronic obstructive pulmonary disease (COPD) requiring home nasal oxygen; polysubstance abuse including tobacco, alcohol, and cocaine; and medication non-compliance. Electrocardiogram (EKG) showed sinus rhythm with left bundle branch block. Labs revealed pro-brain natriuretic peptide (BNP) over 3600, elevated troponin panel in a flat pattern consistent with heart failure, and urine toxicology positive for cocaine. Chest film showed severe cardiomegaly. Treatment included DuoNeb nebulizer, aspirin, and intravenous Lasix 40 
milligrams (mg). She was treated with guideline-directed medical therapy (GDMT) and by day #3, she was transitioned to oral Lasix and counseled extensively on medication compliance. Renal function improved with a creatinine of 1.2. The patient declined substance abuse rehab, refused telemetry monitoring, and left against medical advice. The requested coverage for inpatient hospital admission was denied based on policy, and the patient is appealing the decision.

The requested health service was not medically necessary.

Based on the peer-reviewed medical literature, criteria for inpatient admission are not met, including hemodynamic instability; respiratory distress; pulmonary edema; angina with acute coronary syndrome; chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection; acute myocardial infarction; pneumonia; hypertension requiring inpatient hospitalization; change in mental status; severe heart failure; cardiac arrhythmias of immediate concern; positive troponin not explained by chronic kidney disease (CKD) and chronic heart failure (CHF), or cerebrovascular accident (CVA) or any other medical condition, symptom, or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient hospital stay. The care the patient received for her decompensated chronic left ventricle systolic heart failure from medical noncompliance, including simply reinstating guideline-directed medical therapy and diuretic, is routinely provided safely and effectively at a 
lower level of care. Therefore, based on the submitted information and the current published medical literature, the requested health service was not medically necessary.