Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical Chest Pain

Treatment inpatient hospital stay

The insurer denied coverage for inpatient hospital stay

The denial is upheld

The patient was admitted to the hospital after presenting with chest pain that caused her to awaken from sleep. Chest pain was associated with leg cramping.  Past medical history was significant for polysubstance abuse, schizoaffective disorder, seizures, remote stroke, hepatitis C virus and frequent evaluations for recurrent chest pain.  The patient was evaluated for similar symptoms one week earlier where cardiac catheterization was performed and revealed non obstructive calcified coronary artery disease.  Echocardiogram [ECG] revealed a left ventricular ejection fraction (LVEF) of 65% [percent].  Upon arrival to the telemetry unit the patient was noted to have stable vital signs with a blood pressure of 97/65 and pulse of 58.  Physical examination demonstrated no abnormality. ECG showed sinus rhythm with a heart rate of 58 and no ischemic abnormalities.  Serum blood testing revealed a mild elevation in high sensitivity Troponin I (22.7, upper limit of normal 20).  The patient was treated medically and transferred back to the psychiatry unit the following day.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. This patient presented with atypical chest pain. Although her pretest probability of coronary artery disease was low to moderate, cardiac catheterization performed a week earlier demonstrated no significant obstruction. (Reference 1) 

Utilizing the HEART (history, electrocardiogram, age, risk factors, troponin) score she was considered low risk for subsequent major adverse cardiac events. (Reference 2) 

Utilizing the TIMI (Thrombolysis in Myocardial Infarction) risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (Reference 3) 

Risk assessment of patients presenting with chest pain and no significant ST (interval on ECG) changes on ECG was reviewed by Hedayati et al. (Reference 3).  

Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  This patient did not meet the MCG (Milliman Care Guidelines) telemetry care guidelines:  Admission is indicated when there is one or more of the following: Suspected or proven acute ischemic cardiac event; Cardiac rhythm disorder or conduction abnormality; New administration or adjustment of treatment affecting cardiac rhythm or conduction; Following cardiac or major thoracic procedure; Cardiac disease; Drug overdose or poisoning; Uncorrected electrolyte abnormalities; or unexplained syncope or other neurologic event. (Reference 4) 

Given the patient's low risk profile, normal ECG, and normal cardiac catheterization one week prior to admission a lower level of care was warranted. 

In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient did not require inpatient hospital admission and could have been treated at a lower level of care.  The health plan acted reasonably with sound medical judgment.

The insurer's denial of coverage for the inpatient hospital stay is upheld. Medical Necessity is not substantiated.