Diagnosis: Chest Pain, Acute Coronary Syndrome.
Treatment: Inpatient admission.

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

This is a male patient with a history of homelessness, chronic obstructive pulmonary disease, hypertension and an immune deficiency disorder. He presented to the Emergency Room (ER) with complaints of intermittent left-sided chest pain, which radiated to his back and arm. He reported that the chest pain had been present for the past several months, but had worsened with deep inspiration and movement in the past few days. He also endorsed shortness of breath, left arm numbness, frequent falls and a dry cough. His vital signs were stable. Two troponin levels were negative. Chest radiography demonstrated no acute pathological findings. An electrocardiogram (EKG) was performed that showed diffuse T-wave inversions, with concern for Wellen's syndrome. It was noted that a repeat EKG was unchanged and consistent with left ventricular hypertrophy. The patient was admitted and ruled out for myocardial infarction. An echocardiogram revealed diffusely hypokinetic wall motion, decreased ejection fraction (left ventricular ejection fraction 15-20%) and normal right ventricular function. Repeat troponin levels were negative. The patient left the hospital against medical advice.

The patient presented with a history of chest pain which was concerning for cardiac etiology. He underwent an appropriate initial evaluation in the Emergency Department, which was unremarkable. This included normal hemodynamics, physical exam, a non-diagnostic EKG and negative cardiac troponins. There were no other high-risk symptoms present to suggest acute coronary syndrome. Although it was medically essential to evaluate the patient's symptoms, inpatient admission was not medically necessary in this instance. The patient's care could have been provided under the observational setting, allowing for additional diagnostic testing. During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia or other medical conditions warranting acute inpatient level of care.

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

The carrier's denial of coverage for the inpatient hospital services is upheld. The medical necessity is not substantiated.