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202112-144330

2022

Fidelis Care New York

Medicaid

Cardiac/ Circulatory Problems

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Cardiac/Circulatory Problems.
Treatment: Inpatient Hospital.
The insurer denied inpatient stay.
The denial is upheld in whole.

The patient is a female who was transferred to the hospital from an outlying emergency department where she had presented with chest pain that was precipitated by emotional distress. She was treated with aspirin and enoxaparin and transferred to the hospital for admission to rule out acute coronary syndrome (ACS). Her medical history was remarkable for hypertension, diabetes, chronic obstructive pulmonary disease (COPD), heart failure, obesity, and bipolar disorder. Upon admission her blood pressure was 178/96 millimeters of mercury (mmHg) with a heart rate of 56 beats/minute. Her room air oxygen saturation was 100% (percent). Her physical exam was remarkable for left chest wall tenderness. An electrocardiogram showed sinus rhythm without acute changes. Her serum troponin and brain natriuretic peptide (BNP) levels were normal. A repeat troponin level was again normal. Per the admission history and physical exam, the likely etiology of patient's pain was thought to be musculoskeletal. The next day the patient was in no distress. The following day she reported improvement in her pain but had persistent tenderness on exam. An echocardiogram showed a left ventricular ejection fraction of 45% with inferolateral hypokinesis. There was mild pulmonary hypertension. The patient remained stable and was discharged. The subject under review is the medically necessity for the inpatient stay.

The health plan's determination is upheld in whole.

This patient, with multiple cardiac risk factors, presented with atypical symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, monitoring until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers, and no acute ischemic electrocardiographic changes. She did not require intensive monitoring or continuous 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 both safe and is in accordance with current guidelines, including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE)/American College of Chest Physicians (CHEST)/Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT)/Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes. The patient could have been managed at a lower level of care status.

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