Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department (ED) with chest pain and lightheadedness. The patient reported symptoms for 2 days in a row. The chest pain, described as tightness, lasted for 3 hours. It started at rest. The patient reported no previous cardiac history. The tightness improved with walking and sleeping.
The patient has a history of diabetes mellitus (DM), hypertension (HTN), hyperlipidemia, chronic back pain and hypothyroidism. The patient has a history of tobacco abuse and quit 2 years ago. He recently noted constipation.
His vital signs in the emergency department (ED) were as a blood pressure (BP) of 146/84, pulse 74 beats per minute (BPM), temperature 98.5 degrees Fahrenheit, oxygen saturation (O2 sat) 94%. His physical examination was unremarkable. His lab results were unremarkable.
His troponin was normal. His creatine kinase (CK), total was elevated; it peaked at 526. A D -dimer was normal. His thyroid stimulating hormone (TSH) was 31. His electrocardiogram (ECG) revealed sinus rhythm without acute ST or T changes. There was a non-specific intraventricular conduction delay. His chest x-ray (CXR) was normal. The patient was admitted to the hospital. Based on an elevated total CK, he was diagnosed with non ST-Elevation Myocardial Infarction (STEMI). The patient was started on intravenous (IV) Heparin. The patient underwent an echocardiogram and it revealed an ejection fraction (EF) of 55% with severe inferolateral wall hypokinesis. The next day after the admission, the patient felt fine, without any chest pain. His serial troponin was normal. The IV Heparin was completed.
The patient was scheduled for a cardiac catheterization, which later was rescheduled. His coronary angiography revealed mid left anterior descending (LAD) 80% stenosis in the proximal segment, 90% stenosis in the mid-segment, 80% stenosis in the distal segment. His left circumflex (LCx) and right coronary artery (RCA) were patent. The patient underwent coronary intervention with 2 drug eluding stents placed in the mid LAD.
The patient tolerated the procedure well. Post procedure the patient was complaining of dyspnea and lightheadedness, similar to prior to admission. He was consulted by an endocrinologist who agreed with an increased dose of thyroid replacement.
The patient was discharged home. An inpatient stay was denied and is under review for medical necessity.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.
The patient presented with atypical chest pain. He had several coronary risk factors (HTN, smoking, hyperlipidemia [HLD] and DM). Therefore, it would be appropriate to observe the patient in the hospital on telemetry unit with serial electrocardiograms (ECG) and cardiac enzymes. However, this could have been done at a lower level of care. The patient ruled out for a myocardial infarction (MI) with serial normal troponins. His ECG did not reveal any ischemic changes. His vital signs were stable. His chest pain resolved. His CXR and lab results were normal. The appropriate management would be to observe for 24 hours and discharge home after serial troponin was normal. However, the patient was diagnosed with non ST-Elevation Myocardial Infarction (NSTEMI) based on an elevated CK. CK (creatine kinase) has at least 3 fractions-creatine kinase myocardial band (CK-MB) [found mostly in the heart muscle], creatine kinase muscle (CK-MM) [found mostly in skeletal muscles] and creatine kinase brain (CK-BB) [found mostly in brain tissue]. Only CK-MB is released from the myocardium. Myocardial damage is demonstrated by measuring a CK-MB index. CK-MB index was not measured. Total CK elevation never was or is used to diagnose myocardial damage. The troponin is much more sensitive and specific. In the presence of a negative troponin in series times 3, myocardial damage (myocardial infarction) should have been ruled out and the CK should have been disregarded. Therefore, the patient did not suffer a NSTEMI. The patient did not have indications for a prolonged hospital stay. He did not have indications for a coronary angiogram and coronary intervention as an inpatient. His coronary artery disease, in LAD territory, was an incidental finding.
In addition, his echocardiogram revealed inferolateral hypokinesis. That implied that the patient had ischemia in RCA or Cx territory, which supplies the inferolateral wall. But his RCA and Cx were patent. However, disease was found in LAD territory, which supplied the anterior wall. Anterior wall was not hypokinetic. In summary, the patient did not have indications for inpatient stay. There were no indications for inpatient admission found based on the medical records.
 Per the first reference: 
"Risk categorization tools such as the Global Registry of Acute Cardiac Events (GRACE) risk score and the Thrombolysis in Myocardial Infarction (TIMI) risk score can be utilized to assess both the acute and long-term likelihood of a further ischemic event following an NSTEMI. Ischemic risk scores have been found to be superior to clinical assessment alone for this purpose. The results of these risk assessments can thus be useful in patient management. Assessment of acute risk guides initial evaluation and selection of care facility, such as a coronary care unit, and the choice of appropriate pharmacotherapy, and guides decision-making regarding invasive revascularization procedures.
The TIMI and GRACE risk scores do not differentiate between type 1 and type 2 MI; however, patients with type 2 MI could be expected to have higher risk scores based on characteristics included in these risk scores such as older age, comorbidities, and prior history of MI. An analysis comparing the characteristics of patients with type 1 and type 2 MI found that those with type 2 MI had a significantly higher mean GRACE score."