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202004-127951

2020

United Healthcare Plan of New York

HMO

Cardiac/ Circulatory Problems

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Chest Pressure, Shortness of Breath

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld.

The is a male patient who has a history of coronary artery disease, Type II diabetes, diabetic nephropathy, chronic kidney disease, seizure disorder, pulmonary embolism, former tobacco abuse, atrial fibrillation, three myocardial infarctions, hypertension, hyperlipidemia, morbid obesity, obstructive sleep apnea (OSA) on continuous positive airway pressure (CPAP), substance abuse, eight cardiac stents, Lithium use, and strokes. He presented to the Emergency Department with complaints of worsening left-sided chest pressure that radiated to the left arm and was accompanied by shortness breath. Vital signs were stable. An EKG revealed normal sinus rhythm with nonspecific T-wave abnormality and a chest x-ray showed mild cardiomegaly. The patient was admitted to the telemetry unit. He ruled out for myocardial infarction with negative cardiac biomarkers. The patient was seen by a Nephrologist and a Cardiologist. Once the patient was medically stable, he was discharged with outpatient follow-up.

The patient presented with chest pain. The initial evaluation in the Emergency Room was unremarkable, including a non-diagnostic EKG and cardiac biomarkers. Inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted; however, inpatient admission criteria were not met. There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting the acute inpatient level of care.

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

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

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