Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain; Shortness of breath

Treatment: Inpatient admission

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

This patient is a male who presents to the Emergency Department (ED) with chest pain. The pain began while he was in bed the previous evening, it was left-sided and radiated to his left flank and back. It was worse on deep inspiration and constant with varying intensities. The pain was also associated with sudden onset of shortness of breath. He states it was worse when lying flat and improved with sitting forward and with albuterol inhalation. He has a past medical history of hypertension, hyperlipidemia, diabetes mellitus, chronic obstructive pulmonary disease (COPD) and thoracic aortic aneurysm. He admits to exertional dyspnea when attempting to walk to the store. He presented with similar atypical symptoms and a stress test at that time was negative. His vital signs recorded in the Emergency Department include; temperature 36.3 C, pulse 74, respirations 18, blood pressure 138/87 and oxygen saturation was 99%. No abnormalities were described on his physical examination. He was discharged home with instructions to follow-up with his primary care physician within one-two weeks.

High-sensitivity cardiac troponin T (hs-cTnT) has 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) 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. 
		
Observation units have been developed to improve care of patients who do not have an obvious clinical condition after their ED evaluation.  Selected people with chest pain are one of the most prominent groups of such patients. They benefit from Observation unit care with standardizing timely and accurate risk assessment, implementation of clinical decision rules, and use of accelerated diagnostic protocols. They are a modern structure for cost-effective, high-quality outpatient / in-hospital patient care. (5)

This patient presented to the hospital with chest pain that was atypical for CAD, since it was described as radiating to his left flank and also that it was made worse with deep inspiration. Troponin x2 was within normal limits and serial EKGs did not show any signs of myocardial injury. The literature that is cited, shows that this patient would have been an appropriate candidate for an Observation unit since, he had no troponin elevations and no changes of injury on his EKG's that were consistent with acute myocardial injury or ischemia. The literature that this reviewer has cited makes it clear that acute hospital admission for this type patient is not medically necessary and that this patient was an ideal candidate for an Observation unit. For this reason, the inpatient admission was not medically necessary.

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

The insurer's denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.