Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a male who presented to the emergency department (ED) complaining of epigastric/chest pain that was worsened with breathing, palpation and position change. He also reported nausea and an episode of vomiting. He had no significant past medical history. In the ED his blood pressure was 154/87 millimeters of mercury (mmHg) with a heart rate of 70 beats per minute. His room air oxygen saturation was 97 percent (%). An electrocardiogram showed sinus rhythm with nonspecific ventricular repolarization (T) wave changes. His serum troponin level was normal. The chest x-ray showed no acute pathology. The patient was treated with Aspirin, Ondansetron and Ketorolac and was admitted to the hospital. His troponin level remained normal. A cardiology consultant opined that his symptoms were likely due to pericarditis or costochondritis and recommended treatment with Colchicine and Naproxen. The patient was discharged.

Based on the documentation provided, an inpatient level of care was not medically necessary. This patient presented with atypical chest pain that was thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under an alternate level of care.
This approach has been shown to be both safe and cost-effective and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT)/Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non- segment (ST)-Elevation Acute Coronary Syndromes.

The health plan's determination of medical necessity is upheld in whole.