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201904-116594

2019

Healthfirst Inc.

Medicaid

Cardiac/ Circulatory Problems

Inpatient Hospital

Medical necessity

Upheld

Case Summary


Diagnosis: Chest pain
Treatment: Inpatient Hospital Admission

Summary: This patient presented to the hospital due to complaints of chest pain. She was sent to the emergency department (ED) via emergency medical services, from her Primary Medical Doctors office because of an abnormal electrocardiogram (EKG) in addition to the chest pain. She has a history of chest pain intermittent for the past year. In the ED she reported she was not experiencing chest pain but the previous evening had chest pain that lasted approximately 10 minutes and resolved on its own. On examination it was noted the patient is in no apparent distress and was not complaining of chest pain. She had one episode of chest pain after admission which lasted 2-3 minutes. But she had not had any further episodes of chest pain since the previous day. The patient was admitted to triage with a history of chest pain radiating to both arms which started the previous night.

The insurer denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

This patient was admitted to the ED with a complaint of chest pain which had occurred intermittently over the past several months. At times it was described as occurring with exertion and relieved by rest. There was no history of palpitations, dizziness or syncope. Recurrent chest pain was not described when she was at the hospital. Troponins X3 were within normal limits, her EKG showed normal sinus rhythm, left ventricular hypertrophy and non-specific repolarization changes. Her echocardiogram showed apical hypertrophy of the left ventricle. Her physicians decided that she needed a cardiac catheterization, which apparently was not available at the initial hospital. The inpatient hospital stay was not medically necessary. The literature recognizes the use of an observation unit for this type of patient. However, a monitored level of care or telemetry unit is not the same thing and the literature that this reviewer has cited shows that a monitored level of care for this patient was not necessary or appropriate.

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