Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest Pain.
Treatment:  Inpatient Hospital.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient presented to the emergency department (ED) with chest pain (pressure) with radiation to left arm and left side of his neck. He had this pain for 5 days.  The patient had diffuse abdominal cramping, generalized myalgias and a headache for 5 days.  He had diarrhea and emesis the day before.

The patient had a medical history of human immunodeficiency virus (HIV) (treatment with highly active antiretroviral therapy (HAART)), hypertension (HTN), hyperlipidemia (HLD), congestive heart failure (CHF), coronary artery disease (CAD), atrial fibrillation (Afib), ventricular tachycardia (VT) post atrioventricular (AV) node ablation, Kaposi Sarcoma with pulmonary involvement, non-ischemic cardiomyopathy (NICM) related to chemotherapy, ejection fraction (EF) 20-25%, severe mitral regurgitation (MR), biventricular implantable cardioverter defibrillator (BV-ICD), on home milrinone, myocardial infarction (MI), obstructive sleep apnea (OSA) on (continuous positive airway pressure (CPAP)), hypothyroidism, secondary hyperparathyroidism, rectal carcinoma, chronic hepatitis (hep) C, anxiety and recurrent major depressive disorder.  His surgical history is significant for herniorrhaphy and gallbladder removal.

A prior left heart catheterization (LHC) revealed 50% left anterior descending (LAD) and anomalous right coronary artery (RCA) off left cusp.  There were 2 recent admissions.  
In the ED, his blood pressure (BP) was 102/69, heart rate (HR) 76, and maximum temperature (Tmax) 37.0 degrees Celsius.  His physical examination revealed "well appearing, sitting comfortably" and no apparent distress.

His physical examination was unremarkable. Lab results revealed a troponin of 0.06, brain (or B-type) natriuretic peptide (BNP) was 245.  He was Rhinovirus ribonucleic acid (RNA) positive.

His urinalysis (UA) was abnormal with white blood cells (WBCs), leukocyte esterase and a hazy appearance.  An electrocardiogram (ECG) was performed and revealed sinus rhythm and biventricular pacing.  His chest x-ray (CXR) revealed left (L) ICD and stable right (R) hilar prominence.

A chest soft tissue ultrasound (US) did not reveal any fluid collection at the site of defibrillator.  The patient was given 500 milliliters (ml) Plasmalyte.

The patient was admitted for chest pain and arm pain in the setting of a febrile illness, rhinovirus upper respiratory infection (URI), possible blood infection from peripherally inserted central catheter (PICC), to rule out acute coronary syndrome (ACS), and for troponin elevation.  He was admitted to telemetry.  Diuretics were held.  The patient was given supportive care for rhinovirus.  His serial troponin was 0.06-0.04.

The patient's condition improved.  He was discharged home.  At issue is the medical necessity of an inpatient level of care.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.

The patient presented with a viral syndrome.  He was febrile, but without evidence of organ injury or other signs of decompensation.  He was observed overnight, and his condition remained stable.  His troponin was elevated very mildly.  He did not have sepsis.  He did not have heart failure exacerbation.  ACS was ruled out.  This patient had a complex cardiac history with multiple procedures; however, during this hospital stay he remained stable, his medications were not changed, and no new tests were done.  Based on above, the patient did not meet inpatient admission criteria.  Care could have been provided at a lower level.