Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intermittent chest discomfort; shortness of breath; and hypertension

Treatment: Inpatient admission (telemetry) 

The insurer denied coverage for inpatient admission (telemetry). The denial was upheld.

This patient is a female who has a past medical history of lupus, hypertension, and seizure, Gastroesophageal reflux disease (GERD). She presented in the emergency room (ED) for chronic symptoms of fatigue, generalized weakness, and dizziness. She feels like her heart is about to fall out, she noticed chest heaviness and feels like she ran out of oxygen. She states that she has been hospitalized five times in the last two months but her symptoms are not improving even though she is taking her medications regularly. She states that she had subjective fever last night and has gained 15 pounds of weight. She has chronic elbow joint pain and has bilateral calf pain and tightness. She denies night sweats, recent travel and palpitations. In her assessment her physician listed problem number one as atypical chest pain. According to the patient and her son, she has been experiencing recurrent episodes of tremors and palpitations associated with acute elevations of blood pressure for one week. 

Because of the patient's improved clinical status and current hemodynamic stability, the decision was made to discharge the patient and continue her workup as an outpatient. At the time of discharge the patient was informed that her serial cardiac enzymes were negative for heart attack and her EKG showed no signs of myocardial injury. No arrhythmias were seen on telemetry monitoring and an Echocardiogram done earlier did not show any significant valvular pathology. She was seen by a cardiologist in the hospital who recommended that a stress test be done as an outpatient. The patient was also told that she was being worked up for the diagnosis of pheochromocytoma and she would see an endocrinologist as an outpatient to complete these studies.

High-sensitivity cardiac troponins 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 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 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.

This patient presented to the ED with symptoms of intermittent chest discomfort, shortness of breath and hypertension. She reported that she had episodes of feeling flushed with associated leg cramping. On initial vital signs her blood pressure was moderately elevated and quickly was controlled using a beta blocker. Serial Troponins x3 were within normal limits and EKG x2 was normal and showed no interval change. The literature recognizes the use of an observation unit for this type of patient. However, a monitored level of care or telemetry unit is not the same thing and the literature that I have cited shows that a monitored level of care for this patient was neither necessary nor appropriate. 

Therefore, the denial of coverage for the inpatient admission (telemetry) should be upheld. 

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