Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain.
Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.  The denial is upheld. 

This is a male patient who was admitted to the hospital with complaints of chest pain and headache.  The complaint was of left-sided chest pain, 10/10 in intensity and associated with right sided weakness and tingling.  The patient's past medical history includes hypertension, hyperlipidemia and coronary artery disease (CAD) status coronary artery bypass graft (CABG) X4. On physical exam he was described as being in no distress.  A grade 2/6 systolic murmur was noted.  A report of an electrocardiogram (EKG or ECG) states that the patient had sinus bradycardia and this is otherwise a normal EKG.  There is no significant change when the EKG was compared with an earlier EKG. Troponin done on days 1 and 2 of admission were both within normal limits.  Chest x-ray showed no acute cardiopulmonary disease. He was seen by a Cardiology consultant and at this time, he was still reporting intermittent chest pain.  The patient has had frequent hospitalizations for chest pain.  He claims that he was taking medications for anxiety.  He denied shortness of breath and leg swelling.  He claims that he is able to walk 2-3 blocks without having shortness of breath.  He smokes 3-4 cigarettes a day and denies drinking alcohol or current use of illicit drugs.  The consultant's opinion was that no acute cardiopulmonary disease was present.  The patient had atypical chest pain which the consultant thought was more likely a panic attack.  

High-sensitivity cardiac troponin 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 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) 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 calculated the negative predictive values of an undetectable hs-cTnT and ECG without ischemia for MI and death within 30 days.  The negative predictive value for MI within 30 days in patients with undetectable hs-cTnT and no ischemic ECG changes was 99.8% (95% confidence interval [CI]: 99.7 to 99.9).  The negative predictive value for death was 100% (95% CI: 99.9 to 100).  They conclude that all patients with chest pain who have an initial hs-cTnT level below 5 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 Emergency Department (ED).

Multiple observation protocols have been developed which have been shown to be safe and deliver effective care.  Recognizing the value of an Observation Unit, studies report that over one third of hospitals now have implemented an ED observation unit.(5,6)

This patient presented to the ED with a complaint of chest pain and shortness of breath that had been present for several hours.  His troponins were negative and his EKG showed no ST segment changes consistent with myocardial injury.  He was placed in a telemetry unit at the time of his admission.  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 cited shows that a monitored level of care for this patient was not necessary.  

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

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