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202003-126410

2020

Empire Healthchoice Assurance Inc.

Indemnity

Cardiac/ Circulatory Problems

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Pericarditis

Treatment: Hospital admission

The insurer denied coverage for hospital admission. The denial is upheld.

This patient is a female with a past medical history of hyperlipidemia who presented to the Emergency Department (ED) with complaints of chest pain. The patient's vital signs were stable. The patient's chest x-ray indicated linear atelectasis at the left lung base. The patient's electrocardiogram (EKG) was suspicious for an ST-elevation myocardial infarction (STEMI) requiring serial EKGs and troponin monitoring. The patient was admitted to the Cardiac Telemetry Unit for telemetry monitoring. The patient's troponin levels were negative. The patient had a transthoracic echocardiogram which indicated an ejection fraction of 66% to 70% with normal left ventricular systolic function and mild aortic regurgitation. The patient's subsequent EKGs indicated diffuse ST elevations in the inferior and lateral leads with no reciprocal changes noted. The clinical impression of the patient's chest pain and electrocardiogram changes were thought to be due to pericarditis. The treatment plan included Colchicine, Ibuprofen and Pantoprazole medications and to monitor for worsening chest pain and signs of hemodynamic instability. The patient was reassessed and cleared for discharge to home with outpatient instructions for a follow up appointment with Cardiology and to continue taking Colchicine, Ibuprofen and Pantoprazole.

Based on the review of the medical record, this was female who presented with a history of shortness of breath and chest pain. Despite these symptoms, the patient's vitals in the ER were stable and her pain was manageable with oral medication, ibuprofen. The patient's clinical workup in the ER and diagnostic studies indicated that this patient's symptoms were consistent with pericarditis. This patient's initial abnormal EKG that was suspicious for acute myocardial infarction warranted further diagnostic testing and monitoring with serial EKGs and troponin. However, considering that this patient's initial troponin was negative and was hemodynamically stable, this patient's further diagnostic testing and monitoring could have been safely provided in the observation level of care. The patient had no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. Thus, inpatient admission was not medically necessary to treat this patient's medical condition.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the hospital admission is not substantiated. The insurer's denial should be upheld.

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