Diagnosis: Dizziness; Chest pain
Treatment: Inpatient admission
The inpatient hospital admission was not medically necessary.
This patient presented for evaluation of chest pain and dizziness. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. The patient was hypertensive on presentation due to non-adherence to the medical therapy, and his pressure improved with therapy within 24 hours. There was no plan for an inpatient ischemic work-up (stress test, CTA [computed tomographic angiography] or catheterization). Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at a lower level of care.