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 presented to the emergency department (ED) with bilateral feet edema, shortness of breath and chest pain radiating to the bilateral shoulders. Her chest pain was present for the previous 3 days. Her symptoms were worse with activity. Her past medical history significant for human immunodeficiency virus (HIV), diabetes mellitus (DM), hypertension (HTN) and hyperlipidemia (HLD). She also had a history of mild asthma. The patient underwent coronary angiography, which revealed normal coronary arteries. The patient has a history of smoking, and alcohol and drug abuse, all remote.
In the ED, the patient was afebrile, her blood pressure (BP) was 126/69, and heart rate (HR) was 73 beats per minute (BPM). Her oxygen saturation (O2 sat) was 97% (percent). The patient was noted to have lower extremity edema.
Her electrocardiogram (ECG) revealed a right bundle branch block (RBBB). Her chest x-ray (CXR) was normal. Her D-dimer was 0.91. Her computed tomography angiography (CTA) was negative for a pulmonary embolism (PE).
In the emergency department (ED), the patient was given aspirin. The patient had ECG changes and ongoing chest pain, and was admitted to the hospital for acute care. She was admitted to a cardiac monitored bed. Her troponin was negative times 3.
The patient underwent an echocardiogram and it was unremarkable. She did not want to take medications prescribed at the hospital and she was insisting on taking her own medications. Her condition remained stable. The patient was discharged home.
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.
She presented with chest pain. She was appropriately evaluated and ruled out for a myocardial infarction (MI). Her condition remained stable, including vital signs and physical examination. Her ECG revealed RBBB, without ischemic changes, her troponin was negative and her chest x-ray (CXR) was unremarkable. The patient refused hospital medications and was continued on her own medications.
An inpatient level of care was not medically necessary. A lower level of care would have been more appropriate.
Per reference 1: "Morbidity and mortality from ST-Elevation Myocardial Infarction (STEMI) can be reduced significantly if patients and bystanders recognize symptoms early, activate the Emergency Medical Services (EMS) system, and thereby shorten the time to definitive treatment. Patients with possible symptoms of STEMI should be transported to the hospital by ambulance rather than by friends or relatives, because there is a significant association between arrival at the ED by ambulance and early reperfusion therapy. In addition, emergency medical technicians (EMTs) and paramedics can provide life-saving interventions (e.g., early cardiopulmonary resuscitation [CPR] and defibrillation) if the patient develops cardiac arrest. Approximately 1 in every 300 patients with chest pain transported to the ED by private vehicle goes into cardiac arrest en route ."