Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems - Chest Pain
Treatment: Inpatient hospital
The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with asthma, hypertension, and hyperlipidemia who presented to the emergency department (ED) with left-sided chest pain. The pain was nonradiating and non-exertional, reported as a pressure-like sensation. The night before the presentation, the patient snorted cocaine. His blood pressure was 126/90 millimeters of mercury (mmHg), his pulse rate was 76 beats per minute, and his respirations were 16 per minute. Cardiac findings include normal radial pulses and normal heart sounds. The lung exam was unremarkable. The patient was neurologically intact. A twelve-lead electrocardiogram (EKG) was completed, showing chronic Vector 2 through Vector 4 convex ST elevations, unchanged from 2020. Laboratory studies revealed a normal chemistry panel. The cardiac troponin I was less than 0.01, and the complete blood count was unremarkable. Cardiology recommended initiating heparin, Brilinta, and aspirin, and admission to the cardiology intensive care unit (ICU). The patient remained chest pain-free. The patient also endorsed drinking alcohol and smoking marijuana. An EKG was repeated, which showed no changes, incomplete right bundle branch block, left anterior fascicular block, and nonspecific ST segment elevations in Vector 2, Vector 3, and Vector 4.

A Coronavirus-2019 (COVID-19) swab was performed and was positive.

Upon admission to the hospital, the patient only endorsed pleuritic chest pain with coughing. A chest x-ray read as a possible aortic arch aneurysm. However, the size of the aorta was unchanged compared to 2020.
The next day the patient remained chest pain-free, and both heparin and Brilinta were discontinued. An echocardiogram was performed, which showed an aortic root diameter of 3.4 centimeters (cm), an ejection fraction of 45 to 50 percent, and normal right ventricle size. The serial cardiac troponins ruled out acute coronary syndrome. The heparin was discontinued, and the patient was placed on baby aspirin, per home dosing. An outpatient computed tomography angiography of the coronary arteries and the aortic arch was recommended. The patient was asymptomatic from a COVID-19 standpoint and did not require advanced treatments. The cause of the chest pain was deemed to be due to cocaine-induced coronary vasospasm. The patient was started on losartan for blood pressure management.

At issue is the medical necessity of the inpatient hospital stay.

The health plan's determination of medical necessity is upheld in whole.

No, the requested health service/treatment of Inpatient Admission was not medically necessary for this patient. The patient was admitted to the hospital because of nonspecific ST segment elevations on the patient's EKG in the setting of left anterior fascicular block and right bundle branch block, which was reportedly relatively similar to previous EKGs. The patient was experiencing chest pain. The cardiac troponin was normal. The concern of the ED was an acute coronary syndrome, and the patient was initiated on heparin and Brilinta. The patient was primarily admitted to rule out acute coronary syndrome with serial cardiac enzymes and telemetry monitoring. When the cardiology team physically assessed the patient, they discontinued the heparin and Brilinta. The cardiac enzymes were negative. The EKG changes were chronic. An echocardiogram revealed no significant pathology. Cocaine-induced coronary vasospasm can be managed under an alternate level of care until the toxic effects of the cocaine expire. The patient did not require continuous vasodilator infusion. There is no evidence of cardiac ischemia due to possible coronary vasospasm. There are no clinical indications for the ICU level of care for this presentation.