Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.

This is a male patient with a history of coronary artery disease and percutaneous coronary intervention. He presented to the Emergency Department (ED) with complaints of chest pain and left arm pain that started approximately a few days prior to presentation. An electrocardiogram was done that showed a sinus rhythm with no ischemia. Laboratory work up was performed; cardiac enzymes were negative and troponin levels were within normal limits.  A chest x-ray was performed that revealed no active pulmonary disease. It was recommended that the patient have a cardiac angiogram, however, the patient declined the test and left against medical advice (AMA). 

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 EKGs which did not show signs of ischemia in patients presenting to the emergency department with chest pain.(4) All patients who sought medical attention for chest pain and had at least 1 hs-cTnT analyzed during two years at the Karolinska University Hospital, Stockholm, Sweden, were included.  They calculated the negative predictive values of an undetectable hs-cTnT and ECG without ischemia for MI and death within 30 days. The negative predictive value for MI within 30 days in patients with undetectable hs-cTnT and no ischemic ECG changes was 99.8% (95% confidence interval [CI]: 99.7 to 99.9).  The negative predictive value for death was 100% (95% CI: 99.9 to 100).  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 ECG have a minimal risk of MI or death within 30 days, and can be safely discharged directly from the ED. 

The use of a simple algorithm incorporating hs-cTnT values at presentation and after 2 hours, as well as absolute changes within the first two hours, provides a safe rule-out or accurate rule-in of acute myocardial infarction and could be performed within two hours in the vast majority of patients presenting with chest pain.  The use of this algorithm seems to be safe, significantly shortens the time needed for rule-out and rule-in of acute myocardial infarction and leaves only 20% of chest pain patients that require more prolonged monitoring and serial blood sampling.(5)

A chest pain observation unit is now commonly used, in many Emergency Departments, to evaluate patients with possible acute coronary syndrome [ACS].  The goal is to arrive at a decision after a finite amount of time, which usually is between 6 and 12 hours [h] but may extend up to 24 h depending on the policies in individual hospitals.  Typically, the patient undergoes a predetermined observation period with serial cardiac biomarkers and ECGs.(6)

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 admission is not substantiated.  The insurer's denial is upheld.