Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: acute hospital inpatient admission
	
The insurer denied coverage for acute hospital inpatient admission. The denial is upheld. 

This patient is a male who came to the Emergency Room (ER) complaining of left-sided chest pain which occurred while he was driving earlier that day. The patient's pain was described as sharp and occurred 1.5 hours prior to his arrival to the ER. The patient's past medical history was significant for hypertension and renal stones. The patient denied shortness of breath, radiation of pain, trauma, fever or cough. The patient reported no history of back pain, diaphoresis or nausea. The patient's pain resolved in the ER and did not recur. The patient listed the severity of his pain as 3 out of 10, severity. There were no aggravating or relieving factors noted. There was no significant past surgical history described and no family history of heart disease. The patient claimed that he did not smoke or drink alcohol. The patient's review of systems was negative, except for what was described above. The patient's cardiac enzymes, EKG, and echocardiogram were all within normal limits. The patient had no further episodes of chest pain while in the hospital. The plan was to discharge the patient with the instructions to follow-up outpatient for his stress test.

High-sensitivity cardiac troponin T (hs-cTnT) is a highly sensitive and early biomarker of myocardial damage (1). Studies have shown that that all patients with chest pain who have an initial hs-cTnT level of <5 ng/l and no signs of ischemia on an electrocardiogram (ECG) have a minimal risk of myocardial infarction (MI) or death within 30 days, and can be safely discharged directly from the Emergency Department (ED).

Many patients admitted to the hospital with cardiorespiratory and other acute syndromes are placed on electrocardiographic monitoring. Such electrocardiographic surveillance theoretically allows the clinical staff to monitor admitted patients for the development of dysrhythmia, both brady- and tachydysrhythmia-in essence, identify patient decompensation and/or clinical deterioration as it occurs rather than after the event. Electrocardiographic monitoring, also known as telemetry monitoring or cardiac monitoring, focuses on the detection of clinically significant dysrhythmia, rather than the diagnosis of acute coronary syndrome (ACS) or acute pulmonary edema. Although electrocardiographic monitoring (ECGM) has advantages and is undoubtedly invaluable in certain patients, significant overuse of cardiac telemetry monitoring does occur.

In this case, this patient presented to the Emergency Department (ED) with a complaint of chest pain that had been present for 1.5 hours. The patient's troponins were negative and his electrocardiogram (EKG) was within normal limits and unchanged from his earlier EKG. The patient was placed in a Telemetry unit at the time of his admission, which was not medically necessary. The literature recognizes the use of an observation unit for this type of patient. However, a monitored level of care or telemetry unit is not the same thing and the literature indicates that a monitored level of care for this patient was not necessary or appropriate. Thus, the inpatient hospital admission for this patient was not medically necessary. This patient could have safely been treated at the observation level of care. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the acute hospital inpatient admission is upheld. The medical necessity is not substantiated.