Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient Stay. 
The denial was upheld in whole.

The patient is a male with a history of atrial fibrillation, hypertension, obesity, and obstructive sleep apnea who presented to the emergency department because of chest pain that was described as intermittent. It started approximately one week before the presentation. Reportedly, the patient was seen by his cardiologist and was recommend an angiogram because of the positive results of the nuclear stress test. Unfortunately, the patient failed to follow through.

When the patient was seen by the admitting physician, he was free of chest pain.

On exam the patient was afebrile, heart rate was 70 beats per minute (bpm), respiratory rate 20, and blood pressure 119/75, with oxygen saturation of 100% on room air. The patient was awake, alert, and oriented, in no acute distress. Head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The cardiovascular exam and pulmonary exam were unremarkable. The abdominal exam was documented as normal.  Chest x-ray revealed gross cardiomegaly but no acute consolidation or infusion.

The patient was admitted to the telemetry floor. He was seen by a cardiologist who recommended an angiogram which revealed severely reduced ejection fraction less than 15% and demonstrated minor luminal irregularities.

The patient was also seen by a pulmonologist who diagnosed the patient with severe obstructive sleep apnea. 

During the hospital stay the patient underwent transesophageal echocardiogram (TEE) and cardioversion. He was started on heart failure medications.

Since the patient remained in stable clinical condition, he was discharged home with a recommendation to follow-up with a cardiologist.

The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

The inpatient stay was not medically necessary for this patient.

The patient presented to the hospital with intermittent chest pain, which resolved quickly. By the time the patient was seen by the admitting physician, the chest pain resolved. At the time, there were no signs of hemodynamic instability or respiratory distress.

There was no evidence of acute coronary syndrome or any other significant abnormality contributing to the chest pain.

There is no doubt that this patient required coronary angiography, which was recommended before this admission due to abnormal results of the stress test. However, this procedure could have been performed at a lower level of care status. The TEE and cardioversion are often performed electively at a lower level of care status.

This determination is in agreement with Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 23rd Edition Criteria for Chest Pain.

These criteria were carefully reviewed. Based on the criteria, admission at the acute inpatient level of care is required in cases of chest pain and hemodynamic instability, respiratory distress, indicative of serious diagnosis other than coronary artery disease, also in cases of angina or myocardial infarction. The review of the medical records clearly demonstrated that the patient had none of the circumstances listed in the criteria.

The inpatient stay was not medically necessary, and the patient could have been treated at a lower level of care status.