Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical Chest Pain and Palpitations

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient presented to the emergency department (ED) complaining of chest pain and palpitations following albuterol used for shortness of breath. The patient reported that pain worsened with deep inspiration and was accompanied by palpitations and heart rates of up to 130 (on his smart watch).  Upon arrival vital signs demonstrated a stable blood pressure (139/91) and pulse was 123bpm (beats per minute).  Past medical history was significant for rhinoplasty two days prior to presentation and asthma.  Physical examination was significant only for packed nares.  ECG (electrocardiogram) revealed sinus tachycardia at a rate of 123.  Serum troponin was not elevated (<0.01ng/ml [nanogram per milliliter]).  computed tomography (CT) angiogram demonstrated no evidence of pulmonary embolism or aortic dissection.  A second Electrocardiogram (ECG) performed revealed sinus rhythm at 69 with J (intervals on ECG) point elevation.  The computer interpretation noted "acute ST (intervals on ECG) elevation MI [myocardial infarction]". The patient had no chest pain at the time of ECG recording. The patient was admitted to the hospital for further observation and was treated with aspirin and intravenous (IV) fluids. Heart rate came down to 70.  He was evaluated by a cardiologist who confirmed lack of ischemic changes on ECG.  Tachycardia was attributed to albuterol use. The patient was subsequently discharged the following day.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. This patient presented with atypical chest pain and palpitations following albuterol use.  He was found to be tachycardic on examination. ECG that reportedly demonstrated an acute myocardial infarction actually demonstrated J point elevation without myocardial infarction. No other abnormalities or findings consistent with an acute coronary syndrome were noted.  Based on history and presentation alone, this patient had a low short-term risk of death and nonfatal cardiac ischemia. (Reference1) Utilizing the HEART (history, ECG, age, risk factors, troponin) score he is considered low risk. (Reference 2) Utilizing the Thrombolysis in Myocardial Infarction TIMI) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days). (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 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. Ultimately this patient was evaluated by a cardiologist and discharged without ischemia work up.  In conclusion, the patient could have been managed at a lower level of care. Acute inpatient admission was not medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient level of care is upheld. Medical Necessity is not substantiated.