Diagnosis: Chest Pain, past medical history includes type II diabetes mellitus and persistent asthma

Treatment: Inpatient admission, diagnostic evaluation, and medication administration

The insurer denied the inpatient stay. The denial was Upheld

The patient presented to the hospital with a chief complaint of intermittent right-sided chest pain, headache and cough of two weeks duration. He stated that the pain was 5/10 in intensity. He was diagnosed with diabetes mellitus in 2016. He reportedly does not follow up with his endocrine physician and is not compliant with his medication, since he frequently forgets to take his insulin. His physical exam did not reveal any abnormalities. Laboratory troponin level was within normal limits. His hemoglobin A1c was 10%. EKG done on day 1 showed sinus rhythm at 63 bpm. He was seen in consultation by the psychiatry department who noted that he has a history of depression and a childhood psychiatric history. The patient says that he sometimes feels depressed and he wants to change things but is not able to do so. The psychiatry consultant suggested routine observation and suggested starting Wellbutrin XL to treat both his depression and attention difficulties. He also recommended Seroquel for agitation. The patient was seen by cardiology consult and cardiac biomarkers were ordered and it was noted that his troponin was within normal limits. A transesophageal echocardiogram was ordered by cardiology but was canceled because the patient refused to take it. There were no acute changes on his electrocardiogram. Endocrinology was consulted for management of the diabetes and he was started on Lantus insulin before meals and metformin was discontinued the patient was closely monitored on the medical/surgical unit under the telemetry service until he was thought to be optimized medically for discharge.

The literature also 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 cited shows that a monitored level of care (telemetry) for this patient was not necessary or appropriate.