Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient hospital admission

The insurer denied coverage inpatient hospital admission. The denial was upheld.

This patient is a male who presented to the ED complaining of chest pain and shortness of breath. He had a past medical history of hypertension. The pain started two days prior to this hospital visit, it was sharp, 9/10 in intensity and was present in the mid chest radiating to the left shoulder. It was worse with deep breathing and changing positions. His chest pain occurred at rest and was unrelated to exertion. He reports being able to do activities of daily living and moderate exercise without chest pain or shortness of breath. He also reports having an episode of dizziness yesterday but he did not have any episode of falling or syncope. He reports having a previous episode of chest pain, shortness of breath and dizziness two years ago when he was admitted to this hospital. Stress test at that time was negative with an ejection fraction of 52%. The patient denied orthopnea, paroxysmal nocturnal dyspnea (PND), and ankle swelling. His review of systems was negative except for what has been mentioned above. The patient was taking amlodipine for his hypertension. The patient was placed on continuous cardiac monitoring which did not reveal any events. Vital signs recorded on a specified date include temperature 97.5, pulse 66, respirations 19, blood pressure 119/67 and oxygen saturation 97% on room air. Chest pain was likely musculoskeletal in origin and the patient was given Tylenol PRN. Chest pain improved and he was medically cleared for discharge.

A 2014 study from Sweden evaluated the significance of undetectable troponin levels and EKGs which did not show signs of ischemia in patients presenting to the emergency department with chest pain.(4)   They conclude that all patients with chest pain who have an initial hs-cTnT level of <5 ng/l and no signs of ischemia on an ECG have a minimal risk of MI or death within 30 days, and can be safely discharged directly from the ED.
  
Multiple observation protocols have been developed which have been shown to be safe and deliver effective care. Recognizing the value of an Observation Unit, studies report that over one third of hospitals now have implemented an ED observation unit. (7)

This patient presented to the hospital with a complaint of chest pain which had been present for two days. He described the pain as sharp and was worse with deep breathing and changing position. On physical exam there was tenderness to palpation in his left chest and also pain when he took deep breaths during examination of his lungs. His troponin levels were all within normal limits which would not be expected if the patient had actual myocardial injury which started two days prior to coming to the hospital. In addition to troponin x3 being normal, his EKG showed no interval change and his transthoracic echocardiogram showed normal left ventricular function. The record indicated that the patient was monitored on telemetry, which was not medically necessary. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.