Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male who presented with atypical chest pain with dyspnea. He was seen in emergency room (ER) with a normal electrocardiogram (EKG) and normal cardiac enzymes. He was hypertensive with an otherwise normal physical exam. He was admitted with "concern for unstable angina". Chest x-ray (CXR) was normal.  Echocardiogram showed normal left ventricular (LV) function and no wall motion abnormality. Cardiac enzymes were negative times three (x3). The patient underwent diagnostic cardiac catheterization that showed normal coronaries. There was no significant disease; post catheterization recovery uneventful. 

No, acute inpatient hospitalization was not medically necessary. 

The patient was always hemodynamically stable with normal vital signs, normal electrocardiogram (EKG), normal echocardiogram, normal cardiac enzymes, normal chest x-ray (CXR), and no ectopy. The only care given after the uncomplicated catheterization was monitoring, intravenous fluids (IVF), and routine medications. This meets definition of outpatient care without any indication for a higher level. Many institutions protocols include a same day discharge.  Most guidelines specify this as an outpatient procedure. 

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome. Exam (blood pressure normalized) and cardiac findings were normal. Biomarkers and electrocardiogram (EKG) showed no evidence of acute ischemia. Chest x-ray was normal. Echocardiogram showed no wall motion abnormality. Enzymes were negative times three. 

The overnight stay for observation and telemetry does not change that determination. All treatment and testing were appropriate at an outpatient status. 

The letter of appeal was carefully considered but it offered no evidence to support a higher level of care. The only care provided was telemetry, frequently performed in observation and outpatient status. The patient was admitted for monitoring and routine post catheterization care; neither required an inpatient level of care. There was no "complex" care that was required in this patient's care post catheterization.  While there is always a potential for an adverse event, one did not happen, and no actual treatment was needed. 

Milliman criteria requirements for acute coronary syndrome (ACS) do not apply as the patient does not meet criteria to support that diagnosis. It is incorrect to label the presentation of this case as unstable angina, as patient was pain free, and electively scheduled for catheterization. Electrocardiogram (EKG) showed no acute changes, and no acute medical treatment was given for acute coronary syndrome (ACS). All testing and therapy would be appropriate, safe and guidelines consistent to be in an outpatient setting. Thus, inpatient level of care was not medically necessary. 

The denial was consistent with guidelines and usual community care. The post-cardiac care as described is routinely performed at a lower level of care.