Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: inpatient admission

The insurer has denied coverage for inpatient admission. The denial was upheld.

The patient is a female who was brought to the Emergency Department (ED) complaining of chest pain. She described chest pain radiating to the back which started approximately one hour prior to presentation and was partially relieved after receiving 162 mg of aspirin given by Emergency Medical Services (EMS). She stated that this was the third episode of similar pain in two weeks. The chest pain was described as sharp and radiating into her back. The pain was worse with a deep breath and associated with dizziness and lightheadedness. She also reported a new onset of bilateral lower extremities swelling which started approximately two weeks ago. She denied recent travel and also denied cough, fever and chills. Past medical history included arthritis, high cholesterol and hypertension. She had no significant past surgical history and had never smoked cigarettes. Initial vital signs included a temperature of 97.6, a heart rate of 63, blood pressure of 123/72, respiration of 16, and an oxygen saturation of 100% on room air. 

Physical exam described the patient as being in no distress, the lungs were clear and the heart rate was regular with no murmurs or gallops heard. There was one plus pedal edema. Laboratory results included a white blood cell (WBC) count of 7.93 and a hematocrit of 37.1. The physician assessment stated that they would admit the patient to rule out acute coronary syndrome (ACS) and would admit her to telemetry monitoring. The chart stated that she was monitored in telemetry for cardiac arrhythmias and to rule out ACS. The planned workup included a nuclear stress test and an echocardiogram. An EKG showed normal sinus rhythm at 60 beats per minute (bpm). The EKG was interpreted as showing right axis deviation, which is not correct since there was right and left arm lead reversal in this EKG. 

There are 4 broad rationales for arrhythmia monitoring. The first is immediate recognition of sudden cardiac arrest to improve time to defibrillation. The second rationale is recognizing deteriorating conditions (i.e., development of early after depolarizations or non-sustained arrhythmias) that may lead to a life-threatening, sustained arrhythmia and thereby prompting treatment that may prevent or mitigate the effects of a cardiac arrest. Third, arrhythmia monitoring will, in many situations, facilitate management of arrhythmias even if not immediately life-threatening. Finally, arrhythmia monitoring can facilitate diagnosis of arrhythmias or cause of symptoms (e.g., syncope and palpitations) and subsequently guide appropriate management.


This patient presented to the hospital with chest pressure and shortness of breath. The pain was described as sharp and made worse by deep inspiration.  The literature cited reviews the indications for telemetry admission, none of which were present in this patient. The hospital states that the patient needed cardiac monitoring that was beyond the scope of observation care.  A telemetry level of care was not medically necessary for this patient and the denial of coverage at the acute level of care should be upheld. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is not substantiated.  The insurer's denial is upheld.