Primary Diagnosis: Cardiac/Circulatory Problems
Primary Treatment: Inpatient Hospital

The patient is a woman with past medical history significant for hypertension (HTN), hyperlipidemia (HLP), obesity, gastroesophageal reflux disease (GERD), obesity, bipolar disorder, methadone dependence, and recent endometrial biopsy, who presented to the emergency department with chief complaints of chest pain at rest, dyspnea on exertion, weakness and dizziness as well as right leg pain. On presentation to the emergency department, she was noted to have vital signs and the rest of her physical exam within normal limits. A chest x-ray (CXR) showed no acute process and an electrocardiogram (EKG) did not reveal evidence of acute ischemia or arrhythmia. The health plan denied the inpatient stay as not medically necessary. The health plan's determination is upheld.

This patient had numerous risk factors for acute coronary syndrome but presented with atypical chest pain given it had been ongoing for two days without associated EKG changes or elevation of troponin. She was not having cardiac arrhythmia. Given her numerous risk factors for coronary artery disease, she was certainly appropriate to observe, but it is unclear why acute inpatient admission was medically necessary in the absence of evidence of acute coronary syndrome, arrhythmia, hemodynamic instability, hypoxia, or other reason for acute inpatient admission. The patient could have been treated at a lower level of care.