Diagnosis: Chest Pain
Treatment: Inpatient admission

The insurer denied the inpatient admission.
The denial is upheld.

This male patient was hospitalized for chest pain. He was transferred from another facility for cardiac catheterization to evaluate chest pain that had been present for several days. His past medical history is pertinent for hypertension (HTN), hyperlipidemia (HLP), diabetes, paroxysmal atrial fibrillation, benign prostatic hyperplasia (BPH) and chronic eosinophilia.

The patient's vital signs were stable. Electrocardiogram (EKG) showed sinus rhythm (SR) and right bundle branch block (RBBB). There were no arrhythmias or elevated troponin documented. Chest x-ray revealed calcification of the aortic arch. Echocardiogram showed left ventricular ejection fraction (LVEF) of 60%. Cardiac catheterization showed severe single-vessel coronary artery disease (CAD) and he underwent successful percutaneous coronary intervention (PCI) with stenting to the mid left anterior descending (LAD) coronary artery. There were no procedural complications and the patient was discharged to home the next day. This is an appeal of the denied claim that the requested acute inpatient hospital stay was medically necessary for this patient.

No, the proposed inpatient hospital admission was not medically necessary.
Based on the peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria for inpatient admission is not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome (ACS), chest pain that is indicative of a serious cardiac condition like acute myocardial infarction (AMI), pulmonary embolism (PE) or aortic dissection, pneumonia, hypertension requiring inpatient hospitalization, significant procedural complication or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. The care the patient received, including an uncomplicated cardiac catheterization with percutaneous coronary intervention (PCI) like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, the proposed treatment is not medically necessary, based on the submitted information and the current published medical literature standards of care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient