Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory.
Inpatient Hospital.

Diagnosis: Chest Pain.
Treatment Inpatient Hospital.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department with complaints of palpitations, chest pain, and shortness of breath that occurred after substance consumption.
At the time of admission, the patient denied a fever, chills, nausea, vomiting, orthopnea, paroxysmal nocturnal dyspnea, dyspnea on exertion, or any other complaints. He endorsed similar complaints in the setting of similar substance use in the past. By the time the patient was seen by the admitting physician, he was completely asymptomatic.
At the time of the initial evaluation, the patient was afebrile, the heart rate was 68 beats per minute (bpm), respiratory rate was 18, blood pressure 104-117/62-77, and oxygen saturation 95% on room air.
The patient appeared to be in no acute distress. His lungs were clear to auscultation, he had regular rate and rhythm without murmurs, rubs, or gallops. The abdominal exam was benign. The patient had mild tremors, but otherwise no focal deficits.
An electrocardiogram (EKG) demonstrated normal sinus rhythm, 84 bpm, no acute ST changes. The patient was admitted to the hospital with complaints of chest pain, shortness of breath, and palpitations in the setting of alcohol and cocaine abuse.
It was reported that the patient had a minimally elevated troponin, which was attributed to possible demand ischemia. Therefore, the patient was admitted to the hospital to rule out acute coronary syndrome.
A Clinical Institute Withdrawal Assessment (CIWA) protocol was initiated. The patient received treatment with intravenous fluids, thiamine, folic acid, B12, and multivitamins.
During the hospital stay, the patient's troponins went down to completely normal values. The serial EKGs showed no acute abnormalities to suspect acute coronary syndrome.
During the hospital stay, the patient remained asymptomatic and his chest discomfort resolved after administration of oxygen, Aspirin, and normal saline.
Since the patient remained in stable clinical condition, he was discharged home with a recommendation to follow up in a primary care clinic. 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, shortness of breath, and palpitation one hour after substance consumption. His symptoms were short-lived, and by the time he was seen by the admitting physician, all his symptoms resolved.
When the patient was seen by the admitting physician, he was afebrile and hemodynamically stable. The physical exam was reassuring. The patient had a minimal elevation of the troponin level, which had no clinical significance, especially when his symptoms resolved and the EKGs remained unremarkable. There was no evidence that the patient's symptoms were associated with acute respiratory distress, respiratory failure, heart failure. There was no strong evidence that the patient had an acute coronary syndrome. There was no evidence that the patient had hemodynamic instability or arrhythmia of immediate concern.
Even though the patient was started on the CIWA protocol, there was no clinical evidence that the patient developed alcohol withdrawal symptoms.
The severity of the patient's condition or the complexity of the services provided did not justify admission at the acute inpatient level of care.
Admission to rule out acute coronary syndrome, to ensure control of possible withdrawal symptoms, and to ensure hemodynamic stability could have been performed at a lower 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.