Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer has denied coverage for inpatient admission.
The denial is upheld.

This is a male patient with a past medical history of hypertension, hyperlipidemia, coronary artery disease status post 2 stents gastroesophageal reflux disease and gout. He presented to the emergency department with complaints of chest pain, which improved with sublingual nitroglycerin. The patient reported intermittent chest pain for the prior month and was seeing a cardiologist. Transthoracic echocardiogram (TTE) and stress test done 2-3 weeks prior were unremarkable. Cardiology consulted on the patient, and it was felt that angina was likely secondary to gastritis/GERD. Due to renal dysfunction, the recommended coronary angiography was deferred. Creatinine was 1.63 with recent baseline unknown. Urinalysis was negative for proteinuria. Nephrology consulted and recommended intravenous fluids. The patient had mild improvement to 1.4 and by discharge it was 1.48. The patient was discharged.

The patient presented with chest pain which was relieved by nitroglycerin. His initial evaluation in the ER was unremarkable, including a non-diagnostic EKG and negative cardiac biomarkers. There were no high-risk symptoms suggestive of acute coronary syndrome, rather that of stable angina pectoris. There were no high-risk or concerning findings necessitating further inpatient evaluation or testing. His recommended cardiac catheterization could be performed on an outpatient basis. During the patient's initial evaluation and subsequent hospitalization, he exhibited no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. He had chronic renal insufficiency, which itself is insufficient to substantiate medical necessity for inpatient hospital status. For all of these reasons, the observational level of care would have been appropriate.

The health plan acted reasonably with sound medical judgment 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.