Diagnosis: Cardiac/Circulatory.
Treatment: Inpatient Hospital.
The insurer denied inpatient stay.
The denial is upheld.

The patient is a female who presented to the emergency department complaining of back, left-sided chest and left shoulder pain. Her medical history was remarkable for fatigue. Her blood pressure was 149/90 millimeters of mercury (mmHg) with a heart rate of 69 beats/minute. Her physical exam was unremarkable. Her electrocardiogram and serum troponin level were normal. She was mildly hypokalemic. She was treated with aspirin, potassium, sublingual nitroglycerin and Toradol and admitted to the hospital to rule out acute coronary syndrome. A second troponin level was normal. The patient remained stable and was discharged with plans for a cardiac stress test as an outpatient. Medical necessity for an inpatient stay is at issue.

The health plan's determination is upheld.

This patient presented with atypical symptoms that were thought to be possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. On the other hand, she was hemodynamically stable, with normal cardiac biomarkers, and a normal electrocardiogram. Based on her HEART score of 2 she was at low risk (0.9-1.7%) for major adverse cardiac events. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under a lower level care status. This approach has been shown to be both safe and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.