Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems, Chest pain/other, abnormal echocardiogram results
Treatment: Inpatient stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient initially presented with an abnormal echocardiogram performed at an outside hospital. Pertinent history included chronic obstructive pulmonary disease, current smoker, gastroesophageal reflux disease, and hyperlipidemia. Initial vital signs found the patient to be afebrile and hemodynamically stable. Initial examination documented the patient as alert, oriented, and in no acute distress. An electrocardiogram (EKG) revealed normal sinus rhythm without acute ischemic changes. The patient was placed in the hospital thereafter with an impression of an abnormal echocardiogram and chest pain free. Treatment plan noted nothing by mouth for cardiac catheterization. The next day the cardiologist documented the patient presented with atypical chest pain with an outside hospital echocardiogram that revealed regional wall motion abnormalities. The patient underwent a cardiac catheterization through the right radial artery which revealed non-obstructive coronary artery disease. The following day the patient was deemed medically stable and discharged.

Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission.

McConaghy, et al note approximately 1 percent of primary care office visits are for chest pain, and 1.5 percent of these patients will have unstable angina or acute myocardial infarction. The initial goal in patients presenting with chest pain is to determine if the patient needs to be referred for further testing to rule in or out acute coronary syndrome and myocardial infarction. [1]

The patient initially presented to an outside hospital with shortness of breath and chest pain worsened by a cough. The patient was treated for an acute exacerbation of chronic obstructive pulmonary disease and stabilized. Part of the diagnostic evaluation included an echocardiogram which revealed a left ventricular ejection fraction 50-55% and regional wall motion abnormalities. Thus, the patient was referred for a cardiac catheterization. No cardiac stress testing was noted. Upon admission, the patient was hemodynamically stable and without hypoxia. The cardiologist had an impression of atypical chest pain and an abnormal echocardiogram. Treatment included oral aspirin and a statin. The patient underwent a cardiac catheterization the following day which revealed non-obstructive coronary artery disease. No other issues or complications were documented.

Clinical indications for admission to inpatient care in the setting of angina include concern for unstable angina and ischemic symptoms that warrant acute intervention. [2] In this particular setting, the aforementioned criteria was not met and expert consultation by a cardiologist did not feel this was an acute coronary syndrome. Moreover, There was no documented instability, respiratory distress, or evidence of a myocardial infarction. [3]

While the cardiologist documented indications to perform a cardiac catheterization, the documentation provided did not support an inpatient level of care to manage the patient while this was pursued. Therefore, based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.