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 presented to the emergency department (ED) with worsening chest pain. The chest pain was described as sharp/tightness, 8/10, non-radiating and associated with shortness of breath and diaphoresis. The patient was not complaint with medications. The patient underwent coronary artery bypass graft (CABG) recently.

The requested Inpatient Hospital Admission was not medically necessary for this patient.
The patient with history of coronary artery disease (CAD) and recent coronary artery bypass graft (CABG) presented with chest pain. His pain did not have angina features. His serial troponin was negative and electrocardiogram (ECG) was unchanged. His telemetry revealed stable rhythm.

The patient, from chest pain prospective, did not have indications for inpatient admission. He ruled out for myocardial infarction (MI) and further work up for chest pain could have been accomplished at a lower level. His BP was elevated, but it normalized with oral medications, and there were no reasons to assign inpatient status for transient BP elevation.

His brain (or B-type) natriuretic peptide (BNP) was elevated and cardiology documented diagnosis of heart failure and gave him intravenous (IV) Lasix. However, the diagnosis was established solely based on elevated brain (or B-type) natriuretic peptide (BNP) level. He did not have features of heart failure on physical examination (no jugular vein distention (JVD), crackles, cardiac gallop, murmur, edema orthopnea or paroxysmal nocturnal dyspnea (PND)). His CXR was negative for congestive heart failure (CHF).
BNP can be non-specific in the setting of acute infection, such as viral infection, it is acute phase reactant and could be false positive, as in this case. The patient did not have CHF and inpatient admission was not medically necessary.

The patient presented with pleuritic type of chest pain and he was COVID positive. However, he did not have symptoms or signs of severe COVID infection. No fever, severe dyspnea, myalgia, weakness was noted. His O2 (oxygen) saturation on room air was 93%, probably due to chronic obstructive pulmonary disease (COPD), heavy smoking. His CXR was negative.

Based on that, the patient did not have indications for inpatient admission based on positive COVID infection. The patient left against medical advice (AMA), but even if he stayed, there were no indications for inpatient admission. A lower level of care was appropriate.