Diagnosis: Chest pain.
Treatment: Inpatient admission.

The insurer denied the inpatient admission. The denial is upheld.

The patient is a male with a past medical history significant for HTN (hypertension), COPD (chronic obstructive pulmonary disease), HIV (human immunodeficiency virus), remote history of endocarditis and latent TB (Tuberculosis) diagnosed, s/p (status post) treatment, and alcohol abuse.

The patient presented to the ER with complaints of non-exertional, non-radiating chest pain and shortness of breath. The patient had no fevers, chills, sore throat. An ECG (echocardiogram) revealed no acute ischemic changes. The patient's troponin was 0.05. A urine screen revealed the presence of alcohol. The patient was tachycardic, with stable blood pressure. There was leg edema present bilaterally, with chronic venostasis changes. The patient had normal oxygen saturation. A lung exam revealed no rales or wheezing. The patient's physical examination was unremarkable otherwise. His BNP (brain natriuretic peptide) was not elevated. The patient was admitted to telemetry to rule out ACS (acute coronary syndrome). Echocardiogram was performed, revealing normal LV (left ventricle) function. No inpatient ischemic work-up was planned. The patient was treated for suspected COPD exacerbation and was discharged with a plan for outpatient follow-up.

No, the proposed Inpatient Admission is not "medically necessary".

This patient presented for evaluation of atypical chest pain and dyspnea. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes. No ischemic work-up, such as stress test, CTA (computed tomography angiogram) or catheterization was planned by the treating physicians. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. The symptoms were felt to be related to his underlying COPD, and he was treated with bronchodilators. There was no evidence of acute alcohol withdrawal. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at a lower level of care.