The patient has a history of hypertension, Graves disease and depression. The patient presented to the emergency department complaining of three days of vomiting, diarrhea and throat pain. The patient reported blood streaked emesis. The blood pressure was 133/92 mmHg with a heart rate of 106 beats/minute. The respiratory rate was 18/minute with a room air oxygen saturation of 99%. The patient was afebrile. The patient was admitted to the hospital. The inpatient stay is under review.

The health plan's determination is overturned. The inpatient stay was medically necessary for this patient. This patient presented with atypical symptoms that, given his elevated serum troponin level, were thought to possibly represent acute coronary syndrome (ACS). Given the significant risk for heart failure and potentially lethal arrhythmias in patients with ACS, the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes recommends inpatient admission for patients in whom ACS is suspected and who have elevated cardiac biomarkers. The patient's troponin elevation was ultimately attributed to demand ischemia due to his systemic inflammatory response syndrome (SIRS). While this is not indicative of ACS, elevated troponin levels are common in patients with SIRS and sepsis are are an indicator of poor prognosis. Nearly 80% of patients with SIRS or sepsis and elevated troponin levels develop left ventricular systolic dysfunction; all cause mortality is increased as well. Thus, even in the absence of ACS, the inpatient admission for this high risk patient was medically necessary.