Appeal type: Medical necessity
Decision: Upheld

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

This woman presented to the emergency department complaining of a productive cough, dyspnea, chest pain and a painful lump on her sternum. Her medical history was remarkable for coronary artery disease, coronary artery bypass graft surgery, heart failure with a preserved ejection fraction, diabetes, and hypertension. Her blood pressure was 165/109 millimeters of mercury (mmHg) with a heart rate of 91 beats/minute. Her respiratory rate was 18/minute with a room air oxygen saturation of 98% (percent). She was afebrile. Her physical exam showed clear lungs. There was a tender swelling over her sternum. An electrocardiogram showed sinus rhythm with nonspecific repolarization changes. Her serum troponin and brain (or B-type) natriuretic peptide (BNP) levels were normal. A chest X-ray and computed tomography (CT) scan of the chest showed mild interstitial patchy infiltrates suggestive of atypical pneumonia. Testing for COVID-19 was negative. The patient was treated with Aspirin, a Nitroglycerin patch, Atorvastatin, Plavix, and antibiotics. She was admitted to the hospital to rule out acute coronary syndrome and for the treatment of pneumonia. Her troponin level remained normal. The patient later had no complaints. Amlodipine was prescribed for hypertension. An echocardiogram showed normal left ventricular systolic function. The myocardial perfusion imaging showed no evidence of ischemia. The patient was discharged.

The medical necessity for an inpatient hospital admission is at issue.

I uphold, in whole, the health plan's determination of medically necessary.

Based on the documentation provided, an inpatient level of care was not medically necessary.

This patient presented with atypical chest pain and a cough. She was admitted to the hospital to rule out acute coronary syndrome (ACS) and for treatment of community acquired pneumonia. Given her known coronary artery disease, observation until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers and no acute electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received for her chest pain did not require an inpatient hospital  admission and could have been provided under "observation" status. This approach has been shown to be both safe and cost-effective and is in accordance with current guidelines, including the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR [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), and the Society for Cardiovascular Magnetic Resonance (SCMR)] Guidelines for the Evaluation and Diagnosis of Chest Pain.

The patient was also diagnosed with community acquired pneumonia. She did not have high risk features such as hypoxia, marked tachypnea, altered mental status, fever or hypothermia or pleural effusion. Based on her Pneumonia Severity Index (PSI) and confusion, urea, respiratory rate and blood pressure (CURB-65) risk scores, she was at low risk for major adverse events. Treatment of her pneumonia did not require inpatient hospitalization. The patient's CURB 65 low risk was 0.6%; her 30-day mortality PSI was low risk.