Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

This is a female patient who presented to the Emergency Department (ED) with a five-week history of intermittent chest pain. The patient's past medical history included hypertension, hyperlipidemia, hypothyroidism, migraine, osteoporosis and prior transient ischemic attack (TIA). The patient's initial vital signs were: temperature 97.2, blood pressure 160/100, respiration 16, pulse 56, oxygen saturation 97%, and body mass index (BMI) 24.56. On physical exam, the patient was described as being in no acute distress; no abnormalities were described on her physical exam. The patient's laboratory results included white blood cell (WBC) count 6.9, hematocrit 40.3, sodium 141, potassium 4.1, blood urea nitrogen (BUN) 21, creatinine 0.77, glucose 83 and magnesium 1.8. The patient's troponin levels trended twice were within normal limits, and her D-dimer was 0.27. The patient's lipid profile showed: cholesterol 230, high-density lipoprotein (HDL) 53, triglycerides 47 and low-density lipoprotein (LDL) 168. The patient's electrocardiogram (EKG) showed sinus bradycardia and was otherwise a normal EKG. The patient's chest X-ray showed clear lungs and a distended air-filled loop within the left upper quadrant of the abdomen. At the time of discharge, the patient was advised to take Fosamax, aspirin, Dulcolax, Synthroid and nifedipine. 

High-sensitivity cardiac troponin T (hs-cTnT) has been introduced as a highly sensitive and early biomarker of myocardial damage. 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). A recent study from Sweden evaluated the significance of undetectable troponin levels and electrocardiograms (EKGs) which did not show signs of ischemia in patients presenting to the ED with chest pain. All patients who sought medical attention for chest pain and had at least 1 hs-cTnT analyzed during 2 years were included. 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 ED.

A chest pain observation unit is now commonly used, in many emergency departments, to evaluate patients with possible acute coronary syndrome (ACS). Observation units have been developed to improve care of patients who do not have an obvious clinical condition after their ED evaluation. They are a modern structure for cost-effective, high-quality outpatient/in-hospital patient care. In this case, this patient presented to the ED complaining of chest pain that had been present for several weeks intermittently. The patient's troponin levels and B-type natriuretic peptide (BNP) were within normal limits, and her EKG did not show any ST segment changes consistent with acute myocardial infarction or injury. Certainly, if the patient had an acute coronary syndrome (ACS), abnormal enzymes and an abnormal EKG would be expected after such a long duration of chest pain. The patient's family history was significant for early coronary disease but otherwise, the patient did not have other significant risk factors. The patient's care could have been safely provided at a lower level of care, such as observation status. 

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