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 has a past medical history significant for Parkinson's disease, hypertension, hyperlipidemia, and coronary artery disease and presented to the emergency department with a 2-day history of chest pain, and shortness of breath associated with exertion. The patient stated that the chest pain has been present for 2 days. The patient described the chest pain as intermittent, and not associated with anything in particular. It was right-sided and felt like heaviness. The patient denied any trauma to the area. He said that sleeping on the right side aggravated the pain. In addition, the patient complained of some dyspnea on exertion when he was taking a shower. The patient denied headaches, nausea, vomiting, or any other acute issues.
When the patient was seen by the admitting physician, he was afebrile. His pulse rate was 58 beats per minute (bpm), respiratory rate 19 breaths/minute, blood pressure 116/73, and oxygen saturation 98% on room air. The patient was in no acute distress. The head, eyes, ears, neck, and 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. On the neurologic exam, the patient had no focal deficits. His gait was normal. The patient appeared anxious.
Laboratory evaluation revealed that white blood cell count was 5.82, hemoglobin 13.2, hematocrit 41.1, and platelets 149. The sodium was 138, potassium 3.5, chloride 106, bicarbonate 24, blood urea nitrogen (BUN) 22, creatinine 0.91, and glucose 169. Liver function tests were unremarkable. The international normalized ratio (INR) was 1.1.
The patient was admitted to the hospital with atypical chest pain. The admitting physician stated that the patient's troponin and proBNP were normal. The patient was ordered a stress test that demonstrated no evidence of ischemia. The echocardiogram was also performed and did not show any clinically significant abnormalities.
Other clinical problems mentioned at the time of admission included Parkinson's disease for which the patient received Sinemet, and anxiety which was treated with Alprazolam.
In the hospital, the patient was seen by a neurologist due to a history of Parkinson's disease. The neurologist did not recommend any changes to the patient's regimen. The patient was also seen by a gastroenterologist due to a history of nonalcoholic fatty liver disease, Barrett's esophagus, and constipation. The patient was recommended outpatient follow-up and weight loss.
In the hospital, the patient was seen by physical and occupational therapists and was recommended for acute rehabilitation. In the hospital, the patient remained in stable clinical condition and was transitioned to outpatient care. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The patient presented to the hospital with complaints of chest pain and shortness of breath. However, the review of the medical records demonstrated that his symptoms were not associated with hemodynamic instability or respiratory distress. There was no clinical evidence that the patient had angina or myocardial infarction. The chest pain was not indicative of a serious diagnosis other than coronary artery disease.
During the hospital stay, the patient did not need any evaluation or procedure that would necessitate admission at the acute inpatient level of care. Therefore, there was no overwhelming reason that either the severity of the patient's condition or the complexity of services provided rose to the acute inpatient level of care.
Overall, he remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.