Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
 
Treatment: Inpatient hospital admission

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

This patient is a female who presented to the emergency department (ED) with left-sided reproducible chest pain. She has a past medical history which includes recurrent asthma, cigarette smoking, hypertension, hyperlipidemia, chronic headache/migraines with photophobia, on methadone program for many years, chronic dizziness associated with chronic headache and seizures. The pain started suddenly and was described as a pulling aching sensation and was reproducible when she touches her chest. She also describes chronic headache with photophobia. Her vital signs include BP 149/96, pulse 112, temperature 98.6, respirations 18, oxygen saturation 100% and BMI 33.20. There were no abnormalities described on her physical exam. Laboratory results include sodium 134, potassium 4.9, BUN 18, creatinine 0.68, hematocrit 32.7. Hemoglobin A1c 5.0, WBC 5.4 and troponin X2 were within normal limits. The physician's assessment and plan listed chest pain R/O ACS. The plan was serial cardiac biomarkers/EKGs, transthoracic echocardiogram in a.m. and cardiac monitoring for possible arrhythmias.

High-sensitivity cardiac troponin T (hs-cTnT) has 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. 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.

Observation units have been developed to improve care of patients who do not have an obvious clinical condition after their ED evaluation. Selected people with chest pain is one of the most prominent groups of such patients. They benefit from observation unit care with standardizing timely and accurate risk assessment, implementation of clinical decision rules, and use of accelerated diagnostic protocols. They are a modern structure for cost-effective, high-quality outpatient/in-hospital patient care. (5)

This patient presented to the hospital with chest pain that was atypical for CAD. She described the pain as a pulling sensation which was reproducible when she touches her chest. She also described headaches with photophobia which was consistent with her prior history of migraine. Troponin X2 were in within normal limits and her EKG did not show any signs of myocardial injury. The literature cited shows that this patient would have been an appropriate candidate for an observation unit since she had no troponin elevations and no changes of injury on her EKG that were consistent with acute myocardial injury or ischemia. The acute hospital admission for this type patient is not medically necessary.

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.