Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest Pain
 
Treatment:  Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was upheld.  

This is a male patient with a medical history that included diabetes mellitus, hypertension, high cholesterol, an automatic implantable cardioverter defibrillator (AICD) insertion, herniated disc, coronary artery disease (CAD), heart failure within an AICD implanted.  The patient's home medications included losartan, metformin, atorvastatin, albuterol and oxycodone as needed (PRN).  The patient's initial vital signs in the ED included a temperature of 98.2, a pulse of 98, respirations of 18, blood pressure of 162/79, and oxygen saturation of 97%.  On physical examination he was described as being in no apparent distress with mild alcohol on his breath.  He denied complaints of cough or shortness of breath.  He was consulted by Cardiology.  He was monitored on telemetry.  An electrocardiogram (EKG) was preformed that revealed a normal sinus rhythm.  A chest x-ray was done which showed no acute pulmonary abnormalities.  A Nuclear SPECT myocardial perfusion imaging was performed that revealed negative images with mild global hypokinesis with a calculated left ventricular ejection fraction (LVEF) of 37%.  Troponin levels were drawn with negative results.  He was treated with intravenous (IV) fluids for hydration and he received supplemental magnesium to treat his magnesium level of 1.3.  He was discharged home with outpatient follow up instructions. 

High-sensitivity cardiac troponin T (hs-cTnT) have been introduced as a highly sensitive and early biomarker of myocardial damage (1).  In two prospective cohorts of patients admitted to the hospital for chest pain, undetectable hs-cTnT was found to have a very high negative predictive value for myocardial infarction [MI] (2, 3).  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).  All patients who sought medical attention for chest pain and had at least 1 hs-cTnT analyzed during 2 years at the Karolinska University Hospital, Stockholm, Sweden, were included.  They calculated the negative predictive values of an undetectable hs-cTnT and ECG without ischemia for MI and death within 30 days.  The negative predictive value for MI within 30 days in patients with undetectable hs-cTnT and no ischemic ECG changes was 99.8% (95% confidence interval [CI]: 99.7 to 99.9). The negative predictive value for death was 100% (95% CI: 99.9 to 100).  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 Emergency Department [ED] observation unit.

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest. 

The carrier's denial of coverage for the inpatient hospital services from is upheld.  The medical necessity is not substantiated.