Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient admission

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

This patient is a male with a history of tobacco use, hypertension, hyperlipidemia, a myocardial infarction and four stents inserted eight years ago.  He presented to the Emergency Department (ED) with complaints of chest pain.  He received nitroglycerin sublingual once and aspirin at an outpatient clinic prior to arrival in the ED.  His vital signs were: temperature (T) 36.5C, blood pressure (BP) 151/78, heart rate (HR) 90, respiratory rate (RR) 14 and Pulse oximetry (SpO2) 99% on room air.  An electrocardiogram (EKG/ECG) showed normal sinus rhythm.  His lab work was negative for troponin.  A chest x-ray revealed mild pulmonary vascular fullness without pulmonary edema.  An echocardiogram was normal.  He remained stable, underwent an uncomplicated percutaneous coronary intervention (PCI) of the right coronary artery (RCA), and was discharged.

This patient presented with chest pain and remained stable.  There was no congestive heart failure (CHF), respiratory distress, ongoing symptoms suggestive of angina or angina equivalent, severe arrhythmia, hemodynamic instability, suspicion of another serious cause for chest pain, such as a pulmonary embolism (PE) or aortic dissection, need for prolonged cardiac intravenous (IV) medications or oxygen support, introduction of high risk cardiac medications requiring ongoing in-hospital monitoring, severe catheterization or percutaneous coronary intervention (PCI) related complication (i.e. severe bleeding, cerebrovascular accident), or supporting evidence for an acute coronary syndrome such as elevated cardiac biomarkers or an abnormal ECG.

Per Amsterdam EA, et al, (2014), Early Hospital Care:
The standard of care for patients who present with NSTE-ACS, including those with recurrent symptoms, ischemic electrocardiographic changes, or positive cardiac troponins, is admission for inpatient management.  The goals of treatment are the immediate relief of ischemia and the prevention of myocardial Infarction (MI) and death.  Initially, stabilized patients with NSTE-ACS are admitted to an intermediate (or step-down) care unit.

Per Mahler, S.A., et al (2014), Background: The HEART Pathway (history, ECG, age, risk factors, and initial troponin) is an accelerated diagnostic protocol designed to identify low-risk emergency department patients with chest pain for early discharge without stress testing or angiography.  The objective of this study was to determine whether implementation of the HEART Pathway is safe (30-day death and myocardial infarction rate 1% in low-risk patients) and effective (reduces 30-day hospitalizations) in emergency department patients with possible acute coronary syndrome. 

Conclusion: HEART Pathway implementation was associated with decreased hospitalizations, increased identification of MI's, and a very low death and MI rate among low-risk patients.  These findings support use of the HEART Pathway to identify low-risk patients who can be safely discharged without stress testing or angiography."                                                         

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 
     
The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.