This is a patient who presented to the hospital with a past history of diabetes, obesity, hypertension, hypercholesterolemia, peripheral vascular disease, and coronary artery disease. He presented with shortness of breath. He also reported right shoulder pain that he rated as four out of 10 in severity. The health plan's determination of medical necessity is upheld in whole.
The patient had chest pain and a significant history of CAD but cardiac enzymes were negative, EKG was not reported to be consistent with acute ischemia, and he was hemodynamically stable. He did have a complicated past medical history of a cardiac catheterization and peripheral vascular disease (PVD) but overall, he was stable during this admission and ultimately no intervention was performed during the cardiac catheterization. There were also no other aggravating factors, such as acute heart failure, acute kidney injury, pericarditis, or acute pulmonary embolism.