Cardiac/Circulatory Problems - Chest pain
Inpatient Hospital

The patient is a female with a history of hypertension. While undergoing a cardiac stress test, she developed chest pain and lightheadedness. No associated arrhythmias were documented. No ST segment changes were noted. The stress test was stopped; her systolic blood pressure was 120-140 millimeters of mercury (mmHg). Her rhythm was sinus with a rate in the 90s. She was taken to the emergency department. She was alert and hemodynamically stable. There were no acute electrocardiographic changes. Her serum troponin level was normal. She complained of headache; brain computed tomography (CT) scan showed no acute pathology. She was admitted to the hospital to rule out acute coronary syndrome. Two repeat troponin levels were normal. The following day she was asymptomatic and hemodynamically stable. She was transferred to another facility for cardiac catheterization. An echocardiogram showed left ventricular hypertrophy with normal systolic function. There was mild mitral regurgitation, mild aortic stenosis, mild to moderate tricuspid regurgitation and mild pulmonary hypertension. Coronary angiography showed normal coronary arteries. She was discharged home. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld.

Regarding the inpatient admission for cardiac catheterization, this patient was referred for cardiac catheterization after an episode of chest pain and near syncope during stress testing. She had no ischemic electrocardiographic changes and her cardiac biomarkers were normal. Angiography showed normal coronary arteries and the procedure was uncomplicated. The safety of outpatient cardiac catheterization, even when percutaneous intervention is required, has been well demonstrated. An inpatient level of care was not medically necessary.