Cardiac/Circulatory Problems - Chest Pain
Inpatient Hospital
The insurer denied the inpatient stay
The denial is upheld

The patient is an adolescent male with a previous history of asthma on Advair, who was brought to the emergency department with a history of sharp, non-radiating, left-sided chest pain that lasted for 1.5 hours and then self-resolved. On arrival in the ED, he said he still had left-sided chest pain that he rated 2/10 in severity. He did not have sweating, shortness of breath, palpitations, fever, chills, rash, photophobia, or recent viral-like illnesses. He had been camping in August but had not noticed any tick bites.

He was afebrile with a heart rate (HR) of 106 on initial presentation at 728 AM with normal blood pressure and oxygen saturation. At 1251 PM and 229 PM, his heart rates were 66 and 72, respectively. His physical exam was completely normal.

The Cardiologist documented that "serial EKG's reviewed, Subtle ST segment changes which could represent early depolarization. No concerning EKG changes, normal voltages, normal PR and QTc and no ectopy. Multiple EKG's reviewed with no concerning changes or pattern of evolution." The cardiologist wrote that the EKG changes were consistent with a pericarditis and elevated troponin was consistent with a mild myopericarditis, likely from a viral cause. The cardiologist recommended that troponins and EKG's be trended and that ibuprofen and pepcid be used for pain and anti-inflammatory effect.

The health plan denied coverage for the acute inpatient stay.

The health plan's determination is upheld. The patient was only mildly symptomatic on presentation and did not have further symptoms during the hospitalization. The cardiologist documented that the EKG changes were subtle rather than concerning, and that the several EKG's done while the patient was in the ED were without any evidence over time of an evolving cardiac process. The troponins were only mildly elevated and consistent with a myopericarditis. He did not have any cardiac or other condition that required treatment in an acute inpatient setting. There was no concern that he was having a myocardial infarction (MI) or acute coronary syndrome. He was observed during the hospitalization and the serial troponin and EKG's can be performed at a lower level of care.