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202110-142766

2021

Excellus

PPO

Cardiac/ Circulatory Problems

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Shortness of Breath.
Treatment: Inpatient Admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

This patient has a past medical history that includes coronary artery disease with a history of prior stent (or stents) to the left anterior descending (LAD), hypertension, hiatal hernia, hyperlipidemia, and obesity. She presented to the emergency department via ambulance with fatigue, nausea, shortness of breath for three (also reported as four) days, palpitations, chest pressure, near syncope, anxiety and exertional dyspnea which resolved with rest. Symptoms occurred while gardening and ambulating outdoors.

At the hospital, the electrocardiogram (EKG) was normal. Troponin levels were normal X (times) 3 Covid antibody was positive, but subsequent testing was negative. Chest x-ray was unremarkable other than possible hiatal hernia. Vital signs were unremarkable. She was treated with aspirin, clopidogrel, metoprolol, and atorvastatin - all of which were taken as part of her home regimen. The emergency department (ED) planned to admit her "given cardiac Hx [history]". Obstructive sleep apnea was noted with a recommended outpatient sleep study. Symptoms were attributed to deconditioning and to weight gain during covid pandemic.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The patient presented with atypical symptoms with normal EKG and troponin. These findings do not support a diagnosis of ACS [acute coronary syndrome].

For patients who present with symptoms suggestive of an acute cardiac ischemia event, a period of observation is recommended during which electrocardiogram (EKG) and Troponin levels are obtained. If these tests do not indicate the presence of an acute ischemic event, the patient can be further managed as an outpatient. Acute inpatient management is not supported.

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.

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