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

The patient is an adult female. She was hospitalized from for chest pain. She presented to the hospital ED (emergency department) for evaluation of constant chest pain reminiscent of her prior chest pain when she underwent PCI (percutaneous coronary intervention) with stent to LAD (left anterior descending) several months ago. Her past medical history is pertinent for mild HTN (hypertension), HLP (hyperlipidemia), GERD (gastroesophageal reflux disease) and hypothyroidism.
The patient's vital signs were stable: BP (blood pressure) 119/56, HR (heart rate) 59, RR (respiration rate) 18, oxygen saturation 95 percent (%) on RA (room air). EKGs (electrocardiograms) showed SR (sinus rhythm) and were normal. There were no arrhythmias reported. Troponin panel was negative. The clinical impression was GERD (gastroesophageal reflux disease)/gastritis. Treatment included PPI (proton pump inhibitor) and Carafate. The patient was discharged to home.
This is an appeal of the health plan's denial of coverage of the claim for requested acute inpatient hospital stay. The health plan denied coverage on the basis of medical necessity.

The inpatient admission was not medically necessary.

Based on the current 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) 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 inpatient admission is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospitalization. The care that the patient received, including management of chest pain felt to be from gastritis/GERD (gastroesophageal reflux disease) like in this case, 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 inpatient admission was not medically necessary.