Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a history of hypertension and migraine headaches. She presented to the emergency room with a few-day history of left-sided chest pain radiating to the left arm, headache, and nausea. Her vital signs were notable for a blood pressure of 193/105. She was alert and did not appear toxic. The physical exam was otherwise unremarkable. Lab results and a chest x-ray were non-contributory. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The patient was admitted for further treatment and evaluation.
Upon admission to a monitored bed, the patient was treated with oral medications. The next day, the cardiologist evaluated the patient. The unremarkable electrocardiogram (EKG) and cardiac markers were noted, and an outpatient echocardiogram and stress test were recommended. Apparently, the patient refused the outpatient testing and remained as an inpatient. An echocardiogram was completed and was unremarkable. The following day, a stress test was performed and was negative. The entire stay was clinically uneventful, and the patient was discharged. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient admission was not medically necessary for this patient.
Based on a review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG (electrocardiogram) of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no hemodynamic instability, respiratory distress, evidence of heart failure, difficult to control severe pain, or any credible evidence of an acute coronary syndrome. The services provided, oral medications, imaging, stress test, were not at the acute inpatient level of intensity.
Therefore, based on the standard of care, as well as the peer reviewed literature and guidelines cited in the references, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.