Diagnosis: Chest pain

Treatment: Inpatient admission, diagnostic testing, monitoring

The insurer denied the inpatient admission. The denial was upheld.

This patient had a history of hypertension, polio with left lower extremity brace, chronic back pain, anxiety/depression and alcohol abuse with withdrawal seizures. He presented to the emergency department (ED) with a history of chest discomfort for more than a week, and had been in another hospital with similar symptoms one week prior, and discharged after an unremarkable CT angiography of the chest, stress test, and transthoracic echocardiogram. The chest discomfort was described as pressure, radiating to the axilla, and worse with palpation or exertion. Vital signs on presentation: blood pressure (BP) 140/86, heart rate 92, temperature 98.10F, and oxygen saturation on room air 100%. Electrocardiograms (EKG) were normal, as was a chest x-ray. Laboratory test results included white blood cell (WBC) count 5.57, hemoglobin 9.9, and creatinine 0.51. The Troponin High Sensitivity levels were 9, 8, 9, 10, and 9, with reference range <6-14. Coronary angiography revealed 20 to 30% proximal left anterior descending, mid left circumflex, and mid right coronary artery lesions. There were no complications related to this procedure, and he remained stable during his hospitalization.

There is no evidence the patient required an acute inpatient hospital stay to determine that his chest discomfort was not related to acute coronary syndrome (ACS) or for coronary angiography. The testing could have been completed in the emergency department (ED) or at an observation level of care as a same day outpatient procedure.

The denial of coverage for the inpatient hospital stay is upheld. The medical necessity is not substantiated.