The patient presented to the emergency department (ED) with chest pain and dyspnea for the previous 2 days. The patient also felt intermittent numbness of his left hand. The patient had a history of hypertension and hyperlipidemia. Physical examination was unremarkable. An electrocardiogram (ECG) showed no ischemic changes. Laboratory studies including troponin were unremarkable. A Chest computed tomography (CT) in the ED was performed and did not show any significant abnormalities.
The patient was admitted and myocardial infarction (MI) was ruled out. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient had chest pain suggestive of unstable angina. It was reasonable to rule out a myocardial infarction. This could have been done at a lower level of care. Further diagnostic catheterization was reasonable to perform, and once it was clear that there were severe lesions on diagnostic catheterization, intervention was appropriate. Follow-up after the intervention and the subsequent intervention could also have been performed at a lower level of care. The inpatient stay was not medically necessary.