Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient who presented to the emergency department (ED) via Emergency Medical Services (EMS) complaining of chest pain and one week of exertional dyspnea. Her medical history was remarkable for hypertension, asthma, gastroesophageal reflux disease, pulmonary embolism and breast cancer. An electrocardiogram showed sinus rhythm without acute changes. Her serum troponin and brain (or B-type) natriuretic peptide (BNP) levels were normal. A chest x-ray was unremarkable. A chest computed tomography (CT) scan showed no evidence of a pulmonary embolism. There was a cluster of small nodules in the right lower lobe. The patient was treated with aspirin, sublingual nitroglycerin, morphine, famotidine and Mylanta. She was admitted to the hospital. Her troponin level remained normal. She was seen by a cardiologist who recommended cardiac catheterization. This was performed and showed minimal nonobstructive disease. The patient requested consultation with a pulmonologist who noted marked costochondral junction tenderness, likely costochondritis, and recommended a nonsteroidal anti-inflammatory drug, inhaled corticosteroids and beta agonists for her asthma, as well as oral antibiotics for the pulmonary nodules. The consultant opined that they were likely infectious or inflammatory and recommended a follow-up CT scan in 6-8 weeks. The patient was deemed stable for discharge. However, the patient refused to be discharged. She was given 24 hours notice. She reported that she still had intermittent chest pain and was "nervous" and again refused discharge. An echocardiogram was performed and showed normal left ventricular systolic function, grade I diastolic dysfunction and mild mitral regurgitation. The patient was discharged. The medical necessity for an inpatient admission is at issue. 

Based on the documentation provided, an inpatient level of care was not medically necessary. 
This patient presented with symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.