Diagnosis: Rule out acute coronary syndrome (ACS)

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was upheld.

This patient is a male with a history of diabetes, hypertension, current tobacco use, chronic kidney disease, and a positive purified protein derivative (PPD). His home medications included the following; amlodipine, losartan, Lantus, isoniazid, vitamin B6, and vitamin D. The ED triage nurse note lists; Bactrim DS and Percocet, but provider notes do not include these medications. He presented to the ED with a two to three day history of chest pain, increasing the previous night and awakening him from sleep in the morning. The chest pain was described as severe, mid sternal, radiating to his back and left arm and accompanied by dyspnea, dizziness and nausea.

The initial vital signs included: blood pressure 147/83, heart rate 70, respiratory rate 18 and oxygen saturation on room air 100%. The EKG at 12:39 revealed normal sinus rhythm and flat T waves in II, aVL and V6, with no significant change on EKG done. The laboratory test results included white blood cell (WBC) count 10.2, hemoglobin 13.5, BUN 36, creatinine 2.18, potassium 5.6, sodium 132, high sensitivity Troponin T was 16ng/L, and pro-Brain Natriuretic Peptide (BNP) 14.1. The TroponinT level on the day he presented was also 16ng/L (indeterminate level range is 15-51). The lack of change is inconsistent with acute ischemia. He was treated with intravenous saline, with blood urea nitrogen (BUN) 37, potassium 4.3 and creatinine 1.97. The chest x-ray was normal. The test results included normal echocardiography and pharmacological stress test, and ultrasound of the kidneys and bladder revealed only bilateral renal cysts. The medication Losartan was discontinued and he was discharged to home for outpatient follow-up, including his other home medications.

There is no evidence of medical necessity for an inpatient hospital level of care to evaluate or treat this patient's chest discomfort. The evaluation to rule out acute coronary syndrome (ACS) could have been completed in the Emergency Department or at an Observation level of care, followed by outpatient testing. The health plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.