Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Chest Pain
Treatment: Inpatient Hospital Admission
The health plan denied the requested Inpatient Hospital Admission as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with a past medical history significant for diabetes mellitus, hyperlipidemia, hypertension, benign prostatic hyperplasia (BPH), obstructive sleep apnea, and sickle cell trait who presented to the hospital with left-sided chest pain. The pain was intermittent and started 4 days before the presentation.
The patient described the pain as sharp, burning, and lasting 2 minutes at a time. The chest pain was intermittent and unrelated to exertion. The patient was unable to identify modifying factors. His last stress test was performed a couple of years before the presentation and was normal. The cardiac catheterization performed earlier revealed evidence of nonobstructive coronary artery disease.
On the physical exam, the patient was afebrile. His blood pressure was 130/88 millimeters of mercury (mmHg), with a respiratory rate of 18 breaths per minute, a heart rate 63 beats per minute (bpm), and an oxygen saturation of 97% on room air.
The patient appeared to be a well-developed, well-nourished male who was resting comfortably in no acute distress. He was awake, alert, and oriented times three. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that the white blood cell count was 3.0, with a hemoglobin of 12.9, a hematocrit of 40.9, platelets of 150, a sodium of 137, a potassium of 4.3, a chloride of 416, a bicarbonate (HCO3) of 27, a blood urea nitrogen (BUN) of 9.0, and a creatinine of 1.08. Liver function tests were normal. Troponin was normal. An electrocardiogram (EKG) revealed normal sinus rhythm, normal curious complex, and flipped T waves. There was no old EKG to compare.
The patient was admitted to the hospital with chest pain to rule out acute coronary syndrome. The secondary diagnosis was right shoulder pain due to tendinitis. Other clinical diagnoses included hypertension and diabetes mellitus.
While in the hospital, the chest pain resolved. His troponin remained negative.
Considering the patient's risk factors, he was recommended a stress test. However, the patient elected to leave the hospital against medical advice on the day of admission.
At issue is the medical necessity for the inpatient stay.

I uphold, in whole, the health plan's determination of medical necessity.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The patient presented to the hospital with chest pain that was not associated with hemodynamic instability or respiratory distress. Based on the patient's description of the chest pain, results of the laboratory studies, and diagnostic tests, there was no definitive clinical evidence that the patient had angina or an acute myocardial infarction. The chest pain was also not indicative of a serious diagnosis other than coronary artery disease.
Taking into consideration all these facts, and especially the patient's risk factors, the admission for observation at an alternate level of care would have been the most reasonable, in order to rule out acute coronary syndrome and other potentially serious reasons for his symptoms. At the same time, neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care.

Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care. The admission at an alternate level of care would have been justified to ensure stability and adequate response to treatment.