Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a history of hypertension, polysubstance abuse, seizures, antisocial personality disorder, bipolar disorder and chronic pericarditis with acute recurrences.  He was brought to the emergency department from a correctional facility complaining of stabbing, pleuritic, left-sided chest pain of sudden onset. The patient reported an unwitnessed syncopal spell at the time of symptom onset. In the emergency department his blood pressure was 143/91 millimeters of mercury (mmHg) with a heart rate of 62 beats/minute. His cardiovascular exam was unremarkable. His electrocardiogram showed diffuse ST segment elevation that was interpreted as early repolarization. His serum troponin level was normal. His D-dimer and creatine kinase levels were elevated. Head computed tomography (CT) scan showed no acute pathology. Chest X-ray showed no active disease. Lower extremity venous ultrasound showed no evidence of deep vein thrombosis. The following morning he was admitted to the hospital with a diagnosis of atypical chest pain. Repeat troponin level was normal. A ventilation perfusion scan showed no evidence of deep vein thrombosis. The next day the patient continued to complain of chest pain that was treated with oral oxycodone and intravenous morphine. An echocardiogram showed no pericardial effusion. The patient was evaluated by a cardiologist who opined that the ST segment elevation was consistent with pericarditis and recommended treatment with colchicine and a nonsteroidal anti-inflammatory agent. The cardiologist's note indicated that the patient was stable for discharge from a cardiac standpoint. He was discharged the following day. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld.

This patient was admitted with a diagnosis of atypical chest pain. There was some suspicion that this might have represented acute coronary syndrome (ACS). In the case of suspected ACS, it is reasonable to observe and monitor the patient until further testing can be performed, and ACS ruled out. However, this patient was hemodynamically stable, with a normal serum troponin level. His ST segment elevation was not thought to be consistent with acute infarction. He did not require intensive monitoring or infusion of intravenous cardioactive medications. ACS could have been ruled out under a lower level of care status. This approach has been shown to be both safe and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.
Once the patient was seen by a cardiologist it became clear that the initial electrocardiogram interpretation was incorrect and that the ST segment elevation was consistent with pericarditis, not early repolarization. The medical literature indicates that inpatient admission is not necessary for the majority of patients with acute pericarditis. Indications for inpatient admission include fever, anticoagulation, presence of a large effusion or findings of cardiac tamponade, effusion secondary to trauma, immunosuppression, troponin elevation or evidence of myopericarditis. This patient met none of these criteria. Accordingly, an inpatient level of care was not medically necessary on the basis of this patient's pericarditis.
The patient reported an episode of syncope. Per the 2017 ACC/AHA/Heart Rhythm Society (HRS) Guideline for the Evaluation and Management of Patients with Syncope, inpatient admission is recommended for patients presenting with syncope who have a serious medical condition potentially relevant to the cause of syncope identified during initial evaluation. This patient had no such condition identified. The document further states, "In intermediate-risk patients with an unclear cause of syncope, use of a structured emergency department (ED) observation protocol can be effective in reducing hospital admission. Two small randomized controlled trials suggest that structured ED-based protocols, consisting of time-limited observation and expedited access to cardiac testing/consultation, result in reduced health service use without adverse impact on clinical outcomes when compared with unstructured hospital admission." Thus, based on the information provided, an inpatient level of care was not medically necessary on the basis of syncope.