Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This patient presented to the hospital complaining of left sided chest pain similar in character to previous episodes.  Pain severity was a 4/10.  Past medical history was significant for coronary artery disease status post percutaneous coronary intervention (PCI) with a stent placed one month prior to admission, hypertension (HTN), hypercholesterolemia and left hydronephrosis due to chronic bladder obstruction as a result of benign prostatic hypertrophy.  Upon arrival to the emergency department (ED), vital signs were stable blood pressure (BP) 159/89, Pulse 55 blood pressure per minute (bpm) and no abnormal findings were noted on physical examination. 12 lead electrocardiogram (ECG) was unchanged from baseline.  Serial serum troponin levels were not elevated (0.017, 0.014).  Creatinine was mildly elevated, and a computed tomography (CT) scan of the abdomen revealed chronic partial bladder obstruction due to benign prostatic hyperplasia (BPH) and left kidney hydronephrosis.  The patient was maintained on his regular medical regimen and discharged from the hospital. 

The health plan acted reasonably and with sound medical judgement and in the best interest of the patient in this case. 

Acute inpatient hospital admission was not necessary for this patient that presented with chest pain.  His pretest probability of coronary artery disease is intermediate (Reference 1, 2). Risk assessment of patients presenting with chest pain and no significant ST (intervals) changes on ECG was reviewed by Hedayati et al (Reference 3).  Using the History, Electrocardiogram, Age, Risk factors, and initial Troponin (HEART) score risk stratification schema, this patient would have an intermediate 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. These findings are concerning and warrant management and evaluation that includes serial troponin measurement prior to discharge. However, numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care (References 4,5).  They found no significant difference in outcome at 30 days between the two groups.  Fernando Bellolio et al. noted that patients presenting with chest pain, that were managed in an observation unit, had similar 30-day myocardial infarction rates as those admitted to the hospital (Reference 5). 

Admission to the hospital to treat an acute cardiac event was not medically necessary.  The patient could have been managed at a lower level of care. 

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