Diagnosis: Chest Pain
Treatment: Inpatient admission

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

This male was hospitalized chest pain and elevated blood pressure. He presented to the hospital emergency department for evaluation of chest pain since the prior week and elevated blood pressure readings. The clinical impression was possible acute coronary syndrome (ACS) and hypertensive urgency. His past medical history is pertinent for hyperlipidemia (HLP). He was pain free and vital signs revealed his blood pressure was 180/100, The patient's s heart rate was 98, respiratory rate (RR) was 18 and oxygen saturation (O2 sat) was 100% on room air. Follow up blood pressure was 144/102. The patient's electrocardiogram (EKG) was normal. There were no arrhythmias or elevated troponin documented. The patient's lipoprotein (LDL) was elevated to 166. His chest x-ray was negative. The treatment included aspirin (asa) and statin. He did not want to stay over the weekend to have a cardiac catheterization and requested to go home. The patient was advised to follow up with cardiology for one week.

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. Per the Milliman Care Guidelines for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, 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. Therefore, based on the submitted information and the current published medical literature, the proposed treatment was not medically necessary.

Yes, the health plan acted 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.