Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld.

This reviewer was asked to review the case of an adult that presented to the hospital with complaints of sudden onset palpitations, chest pain, elevated blood pressure and concern that the implantable cardiac defibrillator was about to discharge. Past medical history was relevant for non-ischemic heart failure with reduced ejection fraction and hypertension. On arrival to the hospital vital signs were stable (Blood Pressure 185/79, pulse 82). Physical examination revealed no abnormality. 12 lead electrocardiogram (ECG) demonstrated normal sinus rhythm with no significant ST or T wave abnormalities. Serum blood testing failed to demonstrate any elevation in troponin level (<0.006).  Implantable cardioverter-defibrillator (ICD) device interrogation demonstrated no tachycardia or other abnormality. The patient was admitted to the hospital for monitoring and treatment. Echocardiogram demonstrated a normal Left ventricular ejection fraction (LVEF) of 55% (percent) and cardiac catheterization revealed bridging of the left anterior descending artery, elevated left ventricular end diastolic pressure, and no evidence of obstructive coronary disease. The patient was discharged home on medical therapy.

The pretest probability of coronary artery disease is low. (Reference 1) Utilizing the HEART (History, EKG, Age, Risk factors, and troponin) score the patient was considered low risk however the history of cardiomyopathy was concerning. (Reference 2) Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 3) Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events [defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. These findings are concerning and warrant management and evaluation that includes serial troponin measurement, echocardiography and ischemia work up prior to discharge. Numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care. (References 4, 5) They found no significant difference in outcome at 30 days between the two groups. Fernando Bellolio et al. noted that patients presenting with chest pain, that were managed in an observation unit, had similar 30-day myocardial infarction rates as those admitted to the hospital. (Reference 5)  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is not substantiated.