Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated troponin, Hyperglycemia. 
Treatment: Inpatient Hospital Stay. 

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

The patient has a past medical history significant for diabetes mellitus and valve replacement surgery who came to the hospital requesting detoxification from alcohol or cocaine. At the time of the initial evaluation, she was found to have an elevated troponin and hyperglycemia. 
While in the emergency department, the patient received treatment with insulin with normalization of the serum glucose level. When seen by the admitting physician the patient denied chest pain, shortness of breath, palpitations, nausea, vomiting, abdominal pain. The patient admitted to smoking crack cocaine, three-four bags a day, and also drinking a half-pint of liquor. 
When seen by the admitting physician, the patient was afebrile. The blood pressure was 125/89, respiratory rate 18 breaths/minute, pulse rate 110 beats per minute (bpm), and respiratory rate 98% on room air. 
The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. 
The patient was awake, alert, and oriented. The sensory system was grossly normal. She had normal muscle strength. The cranial nerves were within normal limits. A chest x-ray showed no acute cardiopulmonary disease. 
Laboratory evaluation revealed that the white blood cell count was 6.2, hemoglobin 13.7, hematocrit 41.3, and platelets 153. The sodium was 140, potassium 3.2, chloride 99, bicarbonate 29, blood urea nitrogen (BUN) 5.7, and creatinine 0.88. 
The patient was admitted to the hospital with an elevated troponin level, cocaine abuse, history of heart valve replacement with a prostatic valve, uncontrolled diabetes mellitus with hyperglycemia, hyperkalemia, and alcohol dependence. 
In the hospital, the patient was seen by a cardiologist. It was suggested that the patient's elevation of troponin was likely secondary to cocaine abuse and valvular problems. It was unlikely that the patient had an acute coronary syndrome. It was specifically indicated that she denied chest pain, palpitations, shortness of breath. Her echocardiogram revealed a normal left ventricular ejection fraction. 
She was also seen by an endocrinologist who adjusted the patient insulin regimen and started her on Metformin and Jardiance. 
During the hospital stay, the patient did not develop any alcohol withdrawal symptoms. She received potassium supplements for mild hyperkalemia. At the end of the hospitalization, the patient was transitioned to inpatient drug and alcohol rehabilitation.
At issue is the medical necessity of an inpatient stay. 

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

The review of medical records demonstrated that the services could have been provided at the at a lower level of care since neither the severity of the patient's condition nor the complexity of the services provided rose to the acute inpatient level of care. 
Even though the patient had hyperglycemia at the time of the initial evaluation, her blood sugars came down very fast. It was clearly indicated in the history and physical (H&P) note that while still in the emergency department, the patient's blood sugar went down to 129. There was no evidence that the patient had any glycemic emergency. She did not require treatment with an insulin infusion. 
The elevation of troponin did not represent acute coronary syndrome since the patient had no symptoms including chest pain, palpitations, or shortness of breath. She did not need any intervention requiring admission at the acute inpatient level of care for evaluation of mildly elevated troponin levels. 
The patient presented to the hospital for detoxification, however, there was no evidence that she developed alcohol withdrawal symptoms or had severe symptoms of withdrawal from opioids. 
Taking into consideration all of this information, there is not clear evidence that either the severity of the patient's condition or the complexity of the services provided justified admission at the acute inpatient level of care. A lower level of care was warranted to rule out acute coronary syndrome, ensure better blood sugar control, as well as continue monitoring for alcohol withdrawal symptoms.