Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who presented to the emergency department complaining of two weeks of a cough and two days of bilateral rib pain that was worsened with coughing. Her medical history was remarkable for hypertension, hyperlipidemia and asthma. She was afebrile. On physical exam, the patient did not appear to be in respiratory distress. She had mild wheezing. Her anterior chest wall was tender to palpation bilaterally. An electrocardiogram showed sinus rhythm without acute changes. A chest x-ray showed mild left basilar atelectasis and was otherwise unremarkable. Her serum troponin, brain (or B-type) natriuretic peptide (BNP) and D-dimer levels were normal. The patient was treated with nebulized bronchodilators and intravenous steroids with resolution of her wheezing. Her chest pain resolved with acetaminophen. Rib x-rays showed no fracture. She was admitted to the hospital to rule out acute coronary syndrome and for an asthma exacerbation. The patient reported marked improvement in her symptoms. Her chest was clear. Her serum troponin level remained normal. The progress note indicated that stress myocardial perfusion imaging would be performed with possible discharge. The patient's chest remained clear on exam. Myocardial perfusion imaging showed no evidence of ischemia. The patient denied chest pain and reported a minor cough. The progress note indicated that plans for discharge to a shelter were in progress. She was discharged. At issue is the medical necessity of an inpatient stay.

Based on the documentation provided an inpatient level of care was not medically necessary.
This patient presented with atypical chest pain that was worsened with coughing. She was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received for her chest pain did not require an inpatient admission and could have been provided under "observation" status. This approach has been shown to 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 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
The patient also presented with an asthma exacerbation and mild wheezing. The records provided did not document her peak expiratory flow rate. However, she was not tachypneic or hypoxic. She did not have high risk features such as marked breathlessness, inability to speak in full sentences, use of accessory muscles of respiration or drowsiness. She responded to inhaled bronchodilators in the emergency department with resolution of her wheezing. Thus, based on the documentation in the records provided management of this patient's asthma exacerbation did not require an inpatient level of care.