Diagnosis: Chest Pain due to Coronary Artery Disease

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.

This is a male patient who presented to the Emergency Department in early 2019 describing a one hour episode of chest to left arm discomfort at rest, with nausea and dyspnea. He has a history of hypertension, hyperlipidemia and coronary artery disease, with myocardial infarctions, normal left ventricular systolic function, percutaneous intervention with stents in the mid left anterior descending (LAD) and ostial/proximal right coronary artery (RCA), and coronary angiography on earlier that month revealing patent stents and minor coronary artery luminal irregularities. Initial vital signs: blood pressure 150/88, heart rate 98, respiratory rate 16, and oxygen saturation on room air 98%. Chest x-ray was normal and electrocardiogram (EKG) was described as normal sinus rhythm with no ischemic changes. Laboratory test results included white blood cell (WBC) count 5.2, hemoglobin 10.9, creatinine 0.90 and troponin >0.01, with subsequent troponin was also >0.01. He was discharged to home on his home medications.

There is no evidence that this patient required an acute inpatient level of care to determine that his chest discomfort was not related to acute coronary syndrome. This could have been completed in the ED or at an observation level of care. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital services at the acute level of care is upheld. The medical necessity is not substantiated.