The patient is a male with a history of diabetes. He presented to the emergency room with chest pain, shortness of breath, and palpitations. The physical exam and labs were non-contributory. The electrocardiogram (EKG) was negative for ischemia. The patient was admitted for further treatment and evaluation. He was treated with his usual oral medications. Monitoring and serial markers were unremarkable, and he was discharged.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The requested inpatient stay was not medically necessary for this patient. Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, or EKG of an imminently life-threatening cause of the patient's complaints. The services provided - EKG monitoring, serial markers, oral medications - were not at the acute inpatient level of intensity. The patient's care could have been safely and efficiently provided at a lesser level.