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202306-163613

2023

Healthfirst, Inc.

Medicaid

Cardiac/ Circulatory Problems

Inpatient Hospital

Medical necessity

Overturned

Case Summary

Diagnosis: Bilateral Leg Swelling, Exertional Shortness of Breath
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The health plan's determination is overturned.

The patient is a female with a past medical history significant for hypertension, active crack cocaine and alcohol use, active smoker, type 2 diabetes mellitus, and hypothyroidism. She was brought to the emergency department (ED) by Emergency Medical Services (EMS) for evaluation of worsening shortness of breath and leg swelling. In the ED, notable laboratory studies showed an elevated HS cardiac troponin, and fibrin degradation product (d-dimer) was 1516.
The electrocardiogram (ECG) demonstrated normal sinus rhythm, age indeterminate septal infarction with nonspecific segment (ST) abnormalities. The patient was treated with therapeutic Lovenox and admitted to telemetry service under inpatient level of care for evaluation of chest pain and rule out acute coronary syndrome (ACS). The chest computed tomography (CT) was negative for acute pulmonary embolism (PE). The venous dopplers were negative for deep vein thrombosis (DVT). The echocardiogram was obtained showing normal cardiac function, normal wall motion, and moderate left ventricular hypertrophy (LVH). After ACS was ruled out and patient's shortness of breath resolved, the patient was discharged.

The inpatient level of care was medically appropriate and necessary. The patient presented with worsening shortness of breath on exertion and leg swelling and was found to have elevated HS cardiac troponin and d-dimer. She admitted to active crack cocaine use. The ECG in the ED was abnormal revealing septal infarct pattern with nonspecific diffuse ST abnormalities. Given the clinical concern for acute PE and ACS, the patient was appropriately admitted to telemetry service under inpatient level of care given the expectation that hospital care services would be needed for at least 2 midnights. Given the patient's calculated History, Electrocardiogram (EKG), Age, Risk Factors and Troponin (HEART) score was 5 with elevated cardiac troponins indicative of moderately increased risk for short-term adverse cardiac events, the inpatient level of care would be supported by the well-validated HEART pathway and the 2022 American College of Cardiology (ACC) expert consensus decision pathway on the evaluation and disposition of acute chest pain in the emergency department (1-3).

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