Diagnosis: Chest Pain

Treatment hospital admission

The insurer denied coverage for hospital admission.

The denial is upheld.

The patient is an adult female with a past medical history notable for pulmonary embolism, hypertension, iron deficiency anemia, hyperlipidemia, pericarditis, and coronary artery disease with prior coronary stenting. She presented to the Emergency Department (ED) with complaints of intermittent left-sided chest pain. The pain was 10/10 in intensity and radiated to the bilateral upper extremities and upper back. It was associated with upper extremity paresthesia, palpitations, and dizziness. Upon arrival to the ED, the patient's blood pressure was 178/98. Electrocardiogram (EKG) revealed sinus bradycardia with rate of 50, with no ST-T (intervals on EKG) changes. Chest X-ray was unremarkable. The troponin levels were initially and subsequently negative. She was admitted for monitoring. She ruled out for myocardial infarction. Her pain improved with Tylenol. It was suggested that the patient's pain could be attributed to costochondritis. She was discharged with outpatient cardiology follow-up.

The health plan allows for initial evaluation and subsequent monitoring in the hospital under both inpatient and observational levels of care.

The patient presented with complaints of chest pain. Her symptoms were concerning for a cardiac etiology. The patient underwent appropriate initial evaluation in the ED, which was unremarkable. This included an unremarkable physical exam, a normal EKG, and negative cardiac troponins. There were no other high-risk symptoms present to suggest acute coronary syndrome. As medically essential as it was to evaluate the patient's symptoms, inpatient admission was not medically necessary in this instance. The patient's care could have been provided under the observational setting, allowing for additional diagnostic testing. During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. Cardiac troponins remained negative. For all of these reasons, the request did not meet acute inpatient admission, but rather observational level of care.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the hospital admission is upheld. Medical necessity is not substantiated.