Appeal type: Medical necessity
Decision: Upheld

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

The patient has a history of (h/o) atrial septal defect (ASD) repaired 5 years ago and glucose-6-phosphate dehydrogenase (G6PD) deficiency who presented to the emergency room (ER) with a complaint of chest pain. The chest pain began while he was eating a snack, pretzels and apple juice. The pain was left sided, in the lower chest, mid-intensity, non-radiating, non-positional, non-pleuritic, and felt like something moving inside. The pain had been constant since its onset. In the ambulance, he received aspirin 324 milligrams (mg). He denies any recent illnesses or known coronovirus disease (COVID) exposures. He was up to date on vaccines.
He was admitted for non-radiating, non pleuritic, non-positional chest pain with a normal electrocardiogram (EKG) without ST-T changes, negative troponins and creatine kinase-blood (CK-MB) and a chest x-ray (CXR) significant for disruption of inferior most sternal suture wire. The pediatric cardiologist was contacted and the recommendation was for the patient to be admitted for evaluation. The patient was admitted for cardiac monitoring, echocardiogram (ECHO) and long strip electrocardiogram (EKG) in the AM. The following morning patient was reported to have no acute events overnight. The pain was resolving, 2/10 in the left upper abdomen, non-radiating. Labs were reassuring. The physical exam (PE) was nonfocal. The ECHO was completed and returned normal. The EKG was normal, and he was evaluated and cleared by cardiology. During the hospital course, the chest pain resolved. There were no acute events during the hospitalization. On the day of discharge, the patient was hemodynamically stable, tolerating a regular diet, ambulating well and voiding and stooling appropriately. He was instructed to follow-up with the pediatrician in 1 week and follow up with pediatric cardiology in 6 months.

The requested health service/treatment of Inpatient Hospital Admission  was not medically necessary for this patient.
There was no documented finding that would support an inpatient level of care. This patient presented with history of chest pain associated with history of prior cardiac surgery. Nowhere in the medical record provided are unstable vital signs documented. There was no elevation in his cardiac enzymes. His EKG and echocardiogram were both unremarkable. There was no respiratory distress. He did not require IV pain medications to control his pain. He was admitted for less than (<) 24 hours and did not require any highly skilled or technical care during his admission. Chest pain due to a cardiac condition is rare in children and adolescents. Given his benign initial cardiac workup and low prevalence of cardiogenic chest pain in the pediatric population, this patient's medical condition did not require an inpatient level of care to manage and evaluate.
He did not demonstrate hemodynamic instability, respiratory distress, chest pain indicative of serious diagnosis other than coronary artery disease (eg, aortic dissection), angina or myocardial infarction. For these reasons, inpatient level of care was not medically necessary.