Diagnosis: Non-ST (interval on EKG) elevation myocardial infarction

Treatment: Full Hospital Admission

The insurer denied coverage for full hospital admission

The denial is upheld

This is an adult that presented to the hospital after waking up from sleep with dyspnea followed by chest pain and nausea. She had a history of using nocturnal Continuous Positive Airway Pressure (CPAP). Past medical history was significant for hypertension. On arrival to the hospital, she was hypertensive ([blood pressure] BP 210/100 mmHg [millimeters of mercury]). Physical examination revealed bilateral wheezing on lung examination. A 12-lead electrocardiogram (ECG) revealed sinus tachycardia with no evidence of ischemic ST (interval on EKG) or T (interval on EKG) wave abnormalities. Serial serum troponin levels were elevated (758ng/L (nanogram per liter) and 1245ng/L). In addition, she was noted to have an elevated hemoglobin A1c (glycated hemoglobin) levels consistent with newly diagnosed diabetes mellitus. Computerized tomography (CT) chest revealed bibasilar haziness consistent with atelectasis versus bibasilar pneumonia. Echocardiogram demonstrated an inferior wall motion abnormality with a left ventricular ejection fraction (LVEF) of 55% (percent). The patient was diagnosed with non-ST elevation myocardial infarction.

She was transferred to another hospital for cardiac catheterization. Admitting note indicates on arrival she was ambulating in the room, no complaints, examination noted some wheezing especially on the right side. White blood cell (WBC) was 17.1, 14.2 and 13.2. Cardiac catheterization revealed normal coronary arteries and an elevated left ventricular end diastolic pressure. No complications were noted. She was treated with diuretics and discharged.

At the time, the patient was transferred she was clinically stable and underwent cardiac catheterization with no complications. Post catheterization, no complications are noted. The pre catheterization evaluation while contradictory regarding her lung exam, mostly is noted as clear lungs and clinically stable. There was no active acute process that required acute inpatient admission.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.