Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient admission

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

The patient is a male with a history of hypertension and coronary artery disease (CAD) and percutaneous coronary intervention (PCI) X 2 several weeks prior. At the time, the patient had a PCI to the obtuse marginal artery (OM1) and a PCI to an 80% stenosis of the right coronary artery (RCA). The patient presented to the Emergency Department (ED) with complains of chest pain that started while he was driving his car. The patient reported that the pain was in the left chest and it radiated to his neck and left arm. The patient denied any associated shortness of breath, dizziness or diaphoresis. The patient reported that this pain was similar to his previous myocardial infarction (MI). The patient reported taking a sublingual nitroglycerin x1 with minimal relief and reported that his pain was 8 out of 10, in pain intensity. The patient reported that he also had an episode of chest pain the day prior to this ED presentation that occurred at rest and was completely relieved by nitroglycerin. The patient reported that he was a cigarette smoker and had quitted about several weeks prior to this event. 

In the ED, the patient's initial vital signs were: temperature 98.8, heart rate 90, respirations 22, blood pressure 156/93 and oxygen saturation of 100% on room air. The patient's repeat vital signs were: temperature 96.8, heart rate 77, respirations 20, BP 133/73 and oxygen saturation 100%. The patient's physical exam was unremarkable. A note stated that the patient could not safely be discharged home and required further management and should be admitted as an inpatient. 

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 electrocardiograms (EKG) which did not show signs of ischemia in patients presenting to the emergency department with chest pain. They conclude that all patients with chest pain who have an initial hs-cTnT level of <5 ng/l and no signs of ischemia on an EKG have a minimal risk of MI or death within 30 days, and can be safely discharged directly from the Emergency Department (ED).

This patient presented to the Emergency Department (ED) complaining of chest pain. The patient had a cardiac event one week earlier and had percutaneous coronary intervention (PCI) during that hospital admission. The patient was compliant with taking aspirin and Plavix. At this time, the patient received sublingual nitroglycerin prior to arriving to the ED and had no relief. The patient's electrocardiogram (EKG) showed normal sinus rhythm and no acute ST-T-wave changes. This EKG was unchanged from this patient's prior EKG completed. The patient's troponin trended twice were both completely normal, 0.00 ng/ml. The patient's chest x-ray did not show any acute pulmonary disease and there was no evidence of aortic dissection or pulmonary embolism. The literature review indicates that inpatient admission was not medically necessary for this patient.

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 the inpatient admission is not substantiated.  The insurer's denial should be upheld.