Diagnosis: Chest pain
Treatment: Inpatient stay

The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is female with chest pain and shortness of breath for 2 days. The patient reported sharp, pinching chest pain intermittently at the left side of her sternum. (According to the cardiology consult, she described her chest pain as "a little pricking" in the right side of her chest 4/10 at its worse, not related to exertion but worse with inspiration).

The pain started the day prior to admission. She also reported difficulties sleeping during the night secondary shortness of breath. She has 3 pillows orthopnea. She also had mild leg swelling. This was one of her multiple admission with shortness of breath for last several months.

The patient has history of congestive heart failure (CHF), hypertension (HTN), chronic kidney disease (CKD) III and asthma. She also is morbidly obese.

On physical examination her vital signs were normal, she had wheezing and decreased breath sounds. The rest of her physical examination was unremarkable. The patient underwent a computed tomography (CT) angiography, and it revealed no evidence of pulmonary emboli.

The Inpatient Hospital Admission is not medically necessary for this patient. The patient presented with CHF exacerbation and atypical chest pain. Based on her presentation, her CHF exacerbation was mild. Her BNP was not very high, her CXR revealed mild CHF and her physical examination did not suggest severe respiratory distress. The patient responded well to IV Lasix and her condition improved.

The patient had atypical chest pain, and the cardiology service did not believe that she had indication for work up of her chest pain. Her recent coronary angiography was unremarkable. The patient received IV Lasix with good response. Her cardiac MRI could have been performed at a lower level of care.

Based on above, the inpatient level of care was not medically necessary. A lower level would be more appropriate.