Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is the case of a male that presented to the hospital complaining of chest pain that awoke him from sleep followed by weakness and lightheadedness after getting out of bed. The day prior to presentation the patient received the Moderna Coronavirus disease 2019 (COVID-19) vaccine. Upon arrival to the hospital vital signs were stable [blood pressure (BP) 150/100, pulse 96 beats per minute (bpm)]. Orthostatic BP measurements were within normal limits. Physical examination was negative for pertinent abnormal findings. 12 lead electrocardiogram revealed normal sinus rhythm without ischemic ST or T wave abnormality. Serum blood testing revealed no elevation in troponin level [<0.012 nanograms per milliliter (ng/ml)]. Urine toxicology screen was positive for cocaine and marijuana use. The patient was admitted to the hospital for chest pain and near syncope. Computed tomography (CT) head demonstrated no abnormality. Echocardiogram revealed a left ventricular ejection fraction (LVEF) of 45-50% with diffuse left ventricular (LV) hypokinesis. Serial troponin levels were not elevated, and electrocardiogram (EKG) remained unchanged. The patient was discharged with plans for outpatient perfusion testing. 

This patient presented with chest pain and lightheadedness one day following Moderna COVID19 vaccination. In addition, he urine toxicology screen revealed active cocaine use. His pretest probability of coronary artery disease is low. (1) Utilizing the HEART (History, EKG, Age, Risk factors, and troponin) score he was considered low risk. (2) Utilizing the TIMI (Thrombolysis in Myocardial Infarction) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1). (3) Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (3) Using the HEART score risk stratification schema, this patient would have a low 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. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. 

With regard to active cocaine use, inpatient hospital admission was not medically necessary. Investigators studying more than 300,000 hospital admission for chest pain in the setting of cocaine use, found that patients presenting with chest pain following cocaine and no other significant risk factors had a low risk of major adverse cardiac events and mortality. They concluded that most patients did not require hospital admission. (4) 

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

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