Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. At the time of admission to the hospital, he had a past medical history significant for hypertension (HTN), dyslipidemia, chronic obstructive pulmonary disease (COPD), non-obstructive coronary artery disease (CAD), congestive heart failure (CHF) with an ejection fraction (EF) of 20-25%, chronic kidney disease (CKD), and cocaine use disorder. The patient presented for evaluation of chest pain. The patient was admitted for the same complaint and was discharged two days prior to this admission with a plan for outpatient follow-up.

The patient was hemodynamically stable. Electrocardiogram (ECG) did not reveal acute ischemic changes. Troponin was mildly elevated and trended down on repeat labs. The patient was admitted to telemetry to rule out acute coronary syndrome (ACS). No inpatient ischemic work-up, such as stress test or cardiac catheterization, was planned. His medical therapy was adjusted, and the patient was discharged home with a plan for outpatient follow-up.

No, the proposed inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain. He had a known diagnosis of chronic systolic congestive heart failure (CHF). His prior work-up revealed non-obstructive coronary artery disease (CAD). There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. No further ischemic work-up was planned. The patient was discharged on medical therapy with a plan for outpatient follow-up. 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 an observational level of care.