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.