The patient is a male with a past medical history significant for anxiety, hyperglycemia, and marijuana use who presented to the emergency department with complaints of chest pain that he described as pressure. On the physical exam, the patient was afebrile, blood pressure was 147/86, heart rate 88, oxygen saturation 100%. He looked uncomfortable. There was no reproducible chest wall tenderness. The breath sounds were shallow with splinting. At the same time, the lungs were clear to auscultation. The rest of the physical exam was unremarkable. A computed tomography (CT) angiogram of the chest was performed and demonstrated no evidence of pulmonary embolism.
An electrocardiogram (EKG) showed normal sinus rhythm, there were no signs of ST-segment elevation or depression. The patient was admitted to the telemetry floor to rule out acute coronary syndrome. Serial enzymes were ordered. He was seen by a cardiologist. During the hospital stay the patient underwent a stress test, which was normal. Serial troponins were obtained and remained within normal limits. The health plan denied the inpatient admission as not medically necessary. The health plan's determination is upheld.

The main reason for this decision is the fact that the severity of the patient's condition, including lack of alarming features on the physical exam, in the laboratory studies, and also in the diagnostic tests, did not justify admission at the acute inpatient level of care.
Based on a careful review of the patient's records as well as MCG Health Inpatient and Surgical Care 22nd Edition criteria for Chest Pain, standards of care accepted in the US, an admission at the acute inpatient level of care is required in cases of chest pain and hemodynamic instability, respiratory distress, when chest pain is indicative of serious diagnoses such as aortic dissection, or in cases of angina or myocardial infarction.
A careful review of the patient's symptoms, results of the laboratory studies, and diagnostic tests did not reveal that the patient had any of the conditions listed above.