Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.  
The denial is upheld.

The Inpatient admission was not medically necessary.

The patient is a male child with medical history significant for moderate persistent asthma, seasonal allergies, gastroesophageal reflux disease, eczema, and obesity. He was referred to the ED by the Pulmonology Clinic for two-month history of chest pain and hoarseness. The pain was described as daily, persistent, stabbing, centrally located, aggravated by movement, and poorly responsive to Tylenol. Despite the pain, which was described as intense and not changing in intensity, he was able to go to school and participate in his usual activities. He had been evaluated by Cardiology, with unremarkable electrocardiogram and echocardiogram. He had labs done as an outpatient, all within normal limits for age. The plan was for ENT (otolaryngology) evaluation and esophagogastroduodenoscopy (EGD) with Gastroenterology (he had been evaluated by both specialties previously). 

The patient's vital signs in the ED included temperature 36.7, heart rate 92, and respiratory rate 20. Blood pressure at admission was elevated at 148/80. Examination in the ED was brief, and examination upon admission was significant for clear lungs, regular heart rate and rhythm without murmur, benign abdomen, strong pulses, and non-focal neurologic exam. Admission orders included regular diet, Tylenol/ibuprofen as needed, continuation of home asthma medications, and ENT consultation. 

Overnight, the patient slept well with no nurse calls for severe pain. Once psychological screening testing was completed, with high scores for generalized anxiety disorder, Psychiatry was consulted. Recommendations included outpatient referral for therapy related to anxiety, with no medications needed. 

The patient's endoscopy was completed safely, revealing no hiatal hernia, normal esophagus, and patchy erythema of the antral mucosa with occasional erosions. Biopsies were taken at a variety of locations. He was placed on a thirty-day course of omeprazole for mild gastritis. Later, after remaining stable following the endoscopy, he was discharged home, to follow-up with his pediatrician, Pulmonology, and Psychology. 
...
This male child with significant atopic history, gastroesophageal reflux, and obesity was referred through the ED to admit for EGD and ENT consultation because of two-month history of significant chest pain that did not interfere with his daily activities. He had undergone EGD in the past, and had been evaluated by ENT, Cardiology, Pulmonology, and Gastroenterology prior to this admission. He underwent successful EGD with minimal findings and biopsies done. He also had positive screen for anxiety along with some unusual behaviors so Psychiatry was consulted with recommendations for outpatient care. He did not require aggressive pain management and was able to conduct his usual activities of daily living in spite of the pain. While it was not unreasonable to pursue further diagnostic studies in this patient, such studies as the EGD could have been scheduled in the outpatient setting. Psychiatric consultation could have been sought at any time, particularly given the boy's social circumstances and constellation of complaints and behaviors. He did not require acute inpatient admission.