Diagnosis: Chest pain
Treatment: Inpatient admission

The insurer denied the inpatient admission. The denial is overturned. The inpatient admission was medically necessary.

The patient has a past medical history significant for connective tissue disease, rheumatoid arthritis. She presented to the ER for evaluation of new onset chest pain.

The patient was hypertensive with BP (blood pressure) of 168/80. ECG (electrocardiogram) revealed normal sinus rhythm with prolonged QT interval. Chest X-ray was unremarkable. The cardiac troponin was elevated at 1.7, consistent with myocardial injury/NSTEMI (non-ST elevation myocardial infarction). The patient was admitted to telemetry and started on medical regimen for ACS (acute coronary syndrome).

The patient's repeat troponin was trending up to 2.13. The patient underwent cardiac catheterization, and she was found to have non-obstructive CAD (coronary artery disease). Her LV (left ventricle) function was normal. No revascularization procedure was required. The patient was continued on medical therapy and discharged home with a plan for outpatient follow-up.

The patient presented with new onset chest pain, suggestive of unstable angina. The ECG was unrevealing for ACS, but was abnormal, with QT prolongation. Troponin was elevated, and trended up on repeat testing, consistent with myocardial injury/NSTEMI. There was a high index of suspicion for an ACS, and a cardiac catheterization was performed. Given the presentation, elevated cardiac biomarkers, as well as clinical suspicion for an acute coronary syndrome/unstable angina, she would not be an appropriate candidate for an ED chest pain observation unit, and it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.