Appeal type: Medical necessity
Decision: Overturned

Diagnosis: History concerning for unstable angina; hypertension.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is overturned.

The patient is a male, who presented to the cardiologist's office with clinical history concerning for unstable angina. His cardiac risk factors included not well-controlled hypertension (142/101 millimeters of mercury [mm Hg], as documented in the emergency room [ER] records). 

The patient is stated to have a normal electrocardiogram (EKG) as interpreted by the electrocardiogram (EKG) machine; however, this was incorrect; the electrocardiogram is concerning for acute ischemic changes in inferior leads as noted by prominent T-wave inversion in Lead III and subtle ST depression in Lead aVF (arteriovenous fistula).  This abnormal electrocardiogram finding was not documented in the emergency room record. This patient's thrombolysis in myocardial infarction (TIMI) risk score was two, based on concerning unstable anginal presentation and electrocardiogram change. Based on this thrombolysis in myocardial infarction (TIMI) risk score, the patient has an eight percent risk at 14 days of: all-cause mortality, new or recurrent myocardial infarction (MI), or severe recurrent ischemia requiring urgent revascularization. The patient was appropriately admitted as inpatient. He required cardiac catheterization to evaluate for coronary artery blockage and possible revascularization.

Yes, the medical records and accompanying information are sufficient.

The patient's TIMI (thrombolysis in myocardial infarction) risk score was two, based on concerning unstable anginal presentation and electrocardiogram change. The emergency room provider's documentation stating there is no cardiac risk factor for coronary artery disease (CAD) is incorrect; the patient's risk factor for coronary artery disease (CAD) is hypertension. The normal electrocardiogram as interpreted by the electrocardiogram machine was incorrect; the electrocardiogram is concerning for acute ischemic changes in inferior leads as noted by prominent T-wave inversion in Lead III and subtle ST depression in Lead aVF (arteriovenous fistula).  This abnormal electrocardiogram (EKG) finding was not documented in the record.

Yes, the proposed inpatient admission was medically necessary.

The patient's presentation history is concerning for unstable angina, thus suggesting definite/possible acute coronary syndrome (ACS). Per the American College of Cardiology (ACC) guidelines "The standard of care for patients who present with NSTE-ACS (Non-ST elevation-acute coronary syndrome), including those with recurrent symptoms, ischemic electrocardiographic changes, or positive cardiac troponins, is admission for inpatient management". Given ischemic electrocardiogram (EKG) changes on presentation, there was high likelihood of abnormal cardiac catheterization that would have warranted intervention with either percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). This could have resulted in likely anticipated hospital stay more than 48 hours. It is therefore appropriate for inpatient admission. 

Based on thrombolysis in myocardial infarction (TIMI) risk score, patient has eight percent risk at 14 days of: all-cause mortality, new or recurrent myocardial infarction (MI), or severe recurrent ischemia requiring urgent revascularization. Based on the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for acute coronary syndrome (ACS), early invasive risk strategy with coronary angiography is recommended in definite/possible acute coronary syndrome (ACS) patients with thrombolysis in myocardial infarction (TIMI) score greater than or equal to two or electrocardiogram (EKG) changes. Hence, the patient was appropriately taken for cardiac catheterization to evaluate for coronary artery blockage and possible revascularization.  The inpatient admission was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.