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

The patient is a female with a past medical history significant for hypertension, hypertrophic obstructive cardiomyopathy, atrioventricular (AV)-nodal reentrant tachycardia that required ablation in the past, bradycardia, pacemaker placement, hypothyroidism, and gastroesophageal reflux disease (GERD) who presented to the emergency department with complaints of chest pain. The admitting physician stated that the patient was a poor medical historian, most likely because of underlying dementia. The patient complained of palpitations that were associated with chest pain, lightheadedness, and diaphoresis. The pain was exacerbated by leaning forward and relieved by rest.

The patient was admitted to the hospital with the diagnosis of chest pain.
The patient was seen by a cardiologist who recommended ruling out acute coronary syndrome by checking serial troponin and electrocardiogram (EKG).
They also recommended splitting administration of beta-blockers and calcium channel blockers.
Subsequently, in the hospital, the patient remained hemodynamically stable and had no further episodes of chest pain, palpitations, or lightheadedness.
During the hospital stay, she was screened for human immunodeficiency virus (HIV) infection because of her low white blood cell count. The test came back negative.
An echocardiogram was also performed and demonstrated normal left ventricular ejection fraction with changes significant for hypertrophic cardiomyopathy with left ventricular asymmetric septal hypertrophy, which was expected given the patient's history.
The telemetry monitoring demonstrated frequent premature ventricular contractions (PVCs).
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The inpatient hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The review of the medical records clearly demonstrated that the patient had no signs of hemodynamic instability, respiratory distress, chest pain, acute coronary syndrome, or any other serious diagnoses besides coronary artery disease.
The telemetry monitoring did not reveal any evidence of arrhythmias of immediate concern.
During the entire hospital stay, the patient remained in stable clinical condition and did not require any diagnostic tests or procedures that would necessitate admission at the acute inpatient level of care.
Taking into consideration all these facts, neither the severity of the patient's condition nor the complexity of the services provided rose to the acute inpatient level of care.
Considering the patient's complicated cardiac history, the admission for monitoring, and ruling out acute coronary syndrome, and interrogation of the pacemaker was completely reasonable. However, this could have been accomplished at a lower level of care status.