Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male. He was hospitalized for Chest Pain. He presented to the
hospital ED (emergency department) for evaluation of continuous chest pain since
the prior evening. His past medical history is unremarkable.

The patient's vital signs were stable: BP (blood pressure) 108/75, HR (heart rate)
76, O2 sat (oxygen saturation) 96-97% on RA (room air). EKG (electrocardiogram)
showed SR (sinus rhythm) and no acute changes. There were no arrhythmias or
elevated troponin documented. Chest x-ray was normal. Echocardiogram with
Doppler showed LVEF (left ventricle ejection fraction) was 50-55%, and there were
no RWMAs (regional wall motion abnormalities). Treatment included asa (aspirin),
Lovenox and statin.

The clinical impression was costochondritis, and the patient was discharged home on ibuprofen and referral for an OP (outpatient) stress test.

No, the Inpatient admission was not medically necessary.
Based on the peer-reviewed medical literature, there was not a medical need for
the acute inpatient hospital stay. The severity of this patient's illness did not meet
the intensity of service for inpatient hospital stay. Per the MCG (Milliman Care
Guidelines) guideline for Chest Pain, #M-89, criteria for inpatient admission are not
met, including, hemodynamic instability, respiratory distress, pulmonary edema,
angina with acute coronary syndrome, AMI (acute myocardial infarction), chest pain
that is indicative of a serious cardiac condition like pulmonary embolism or aortic
dissection, pneumonia, hypertension requiring inpatient hospitalization 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 is
routinely provided safely and effectively at a lower level of care, such as
Observation. Therefore, based on the submitted information and the current
published medical literature, acute inpatient hospitalization for this patient was not
medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the
best interest of the patient.
The care the patient received is routinely provided safely and effectively at a lower
level of care, such as Observation.

The clinical impression was costochondritis, and the patient was discharged home
on ibuprofen and referral for an OP (outpatient) stress test. This is an appeal of the
denied claim; the requested Acute Inpatient Hospital Stay was not medically necessary
for this patient.