Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain; Shortness of Breath. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

This male patient presented to the hospital with a chief complaint of sub-sternal chest pain and shortness of breath (SOB) for three days. He denied any cardiac history, but has a past medical history of hypertension and diabetes mellitus. He denied abdominal pain, nausea and vomiting. Vital signs include blood pressure (BP) 134/90, heart rate 81, respirations, temperature 93 and oxygen saturation 100%. The chest pain was described as having started three days ago, was persistent without relief and associated with shortness of breath and diaphoresis. He claims that the pain is more severe when he is having a bowel movement. He went to see his primary care physician who did an electrocardiogram (ECG), which was normal and he was told that he did not have to see a Cardiologist. He also complained of a nonproductive cough for two days. 

An ECG was done and showed normal sinus rhythm at 69 beats per minute. Laboratory results include white blood cell (WBC) count 10.41, hematocrit (Hct) 43.9, sodium 141, potassium 3.9, blood urea nitrogen (BUN) 14, creatinine 0.90, and glucose 113. His lipid profile includes cholesterol 120, triglycerides 154, high-density lipoprotein (HDL) 35 and low-density lipoprotein (LDL) 77. Troponin levels were within normal limits. 

The patient stated that he is a former cigarette smoker. No abnormalities are described on the patient's physical examination. No events were noted while the patient was in telemetry. Chest x-ray showed an unremarkable right hilar shadow. 

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 ECGs 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 less than 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 emergency department (ED). Electrocardiographic monitoring, also known as telemetry monitoring, or cardiac monitoring, focuses on the detection of clinically significant dysrhythmia, rather than the diagnosis of acute coronary syndrome (ACS) or acute pulmonary edema. Although electrocardiographic monitoring (ECGM) has advantages and is undoubtedly invaluable in certain patients, significant overuse of cardiac telemetry monitoring does occur. (5) 

This patient presented to the ED with a history of chest pain and SOB of three days duration. His troponin levels were normal which would not be expected if he had ACS and three days of chest pain. His ECG was normal and the patient had no further symptoms after being admitted as an inpatient to telemetry. 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 or telemetry unit for this patient was not necessary or appropriate. 

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

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