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

The patient is a male who presented to the emergency department complaining of non-exertional burning chest pain. His medical history was remarkable for familial hypercholesterolemia. Two days prior he had a computed tomography (CT) scan for coronary calcium scoring. His score was 85, which placed him in the 95th percentile for his age, race and gender. In the emergency department his blood pressure was 203/108 millimeters of mercury (mmHg). This fell to 135/85 mmHg after sublingual nitroglycerin, which also relieved his pain. His heart rate was 87 beats/minute. His physical exam was unremarkable. His electrocardiogram was normal. His serum troponin level was normal and remained normal when re-measured twice. The patient was admitted to the hospital. A stress echocardiogram was performed and showed no evidence of ischemia. The patient was discharged the same day.
The subject under review is the medical necessity for an inpatient hospital admission.

The health plan's determination is upheld.

This patient presented with atypical chest pain. He was hemodynamically stable, with a normal electrocardiogram and normal cardiac biomarkers. Based on his HEART score, he was at low risk for major adverse cardiac events (0.9-1.7%). He 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 of care status. This approach has been shown to be 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.