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

This is a male patient with a past medical history significant for hyperlipidemia, hypertension, active smoking, coronary artery disease (CAD) status/post (s/p) myocardial infarction (MI), and polysubstance abuse who presented to the emergency department (ED) for evaluation of chest pain and shortness of breath. An electrocardiogram (ECG) demonstrated normal sinus rhythm without ischemic changes. A chest x-ray (CXR) demonstrated pulmonary vascular congestion. The high sensitivity (HS) cardiac troponin was high, 95 nanograms per liter (ng/L) but remained flat. The patient was admitted to the telemetry service under an inpatient level of care for evaluation and treatment of possible acute coronary syndrome (ACS). The patient's symptoms improved, and he was discharged in stable condition. At issue is the medical necessity of an inpatient stay.
An inpatient level of care was not medically necessary for evaluation and management of this patient presenting with chest pain.
The patient presented with chest pain and shortness of breath in the setting of noncompliance with taking his home medical therapy. The HS cardiac troponin was elevated but remained flat, consistent with a chronic myocardial injury, not acute coronary syndrome (ACS). The patient's symptoms were deemed likely non-cardiac in etiology. Echocardiogram findings were stable showing a normal left ventricular ejection fraction (LVEF) with normal wall motion. The patient had undergone left heart catheterization (LHC) in the past demonstrating mild non-obstructive CAD. No further inpatient cardiac workup was recommended. Given the patient's symptoms and cardiac troponin elevation were not consistent with ACS, an inpatient level of care was not medically necessary in this case supported by the 2014 American Heart Association (AHA) /American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes and the 2022 ACC expert consensus decision pathway on the evaluation and disposition of acute chest pain in the emergency department (1, 2).