Diagnosis: Chest pain.
Treatment: Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a male who was admitted with chest pain. There was history of myocardial infarction and a stent. The blood pressure (BP) was mildly elevated, however, his other vital signs were normal. Troponin was negative. The electrocardiogram (ECG) was not acute. The creatinine was normal. He underwent a cardiac catheterization which demonstrated a patent left anterior descending (LAD) stent and severe very distal LAD PVD (peripheral venous disease) filling with collaterals. He was medically managed, a nitrate was added, he remained stable and was discharged.

The inpatient hospital admission was not medically necessary. This patient presented with chest pain and remained stable. There was no congestive heart failure (CHF), respiratory distress, ongoing symptoms suggestive of treatment refractory angina or angina equivalent, severe arrhythmia, hemodynamic instability, another serious cause for chest pain, such as a pulmonary embolism (PE) or aortic dissection, need for prolonged intravenous (IV) medications or oxygen support, introduction of high risk medications requiring ongoing in-hospital monitoring, severe catheterization related complication (i.e., severe bleeding, cerebrovascular accident (CVA)), need for invasive hemodynamic monitoring, need for vasopressor or mechanical cardiac support, or supporting evidence for an acute coronary syndrome such as elevated cardiac biomarkers or an abnormal ECG.

In this case an acute inpatient level hospitalization was not medically necessary. A lower level of care was appropriate.