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201906-117734

2019

Healthfirst Inc.

Medicaid

Cardiac/ Circulatory Problems

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Chest Pain

Treatment: Inpatient stay

Summary:
Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary, as this patient could have been treated at a lower level of care.

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