Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain- rule out acute coronary syndrome (ACS).
Treatment:  Inpatient hospital admission.

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

This is a male patient with a medical history of chronic cocaine use and chronic headaches, who presented to the Emergency Department (ED) with a complaint of chest pain.  The patient's respirations were described as even and unlabored.  He denied fever, chills, nausea, vomiting and dizziness.  His psychiatric history was significant for schizophrenia and schizoaffective disorder.  The patient's past medical history was significant for hypertension.  The patient reported that the day prior to presentation was the first time that he used cocaine.  No abnormalities were noted on his physical examination.  Although the patient presented with a history of chest pain, the patient was not complaining of this when he arrived at the ED.  An electrocardiogram (EKG) revealed sinus bradycardia.  There was evidence of left ventricular hypertrophy (LVH).  The EKG was otherwise similar to his last EKG.  The patient's chest X-ray showed that the cardiac silhouette was within normal limits.  The patient's pulmonary vascular bed was normal, and the lung fields were clear.  The impression was that this was a normal chest examination.  The patient's troponin trended three times, were all within normal limits.  The patient reported a history of chronic headaches, and with these headaches, he experienced blurry vision and then becomes sleepy.  The patient had a computed tomography (CT) of the head which showed no evidence of acute intracranial abnormality.  He was admitted to the hospital for further evaluation and management of chest pain and to rule out acute coronary syndrome.  It was planned that he would have a further workup.  However, it was noted on day 3 of admission that the patient had left the hospital against medical advice (AMA). 

High-sensitivity cardiac troponin T (hs-cTnT) has been introduced as a highly sensitive and early biomarker of myocardial damage.  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).  A recent study from Sweden evaluated the significance of undetectable troponin levels and electrocardiograms (EKGs), which did not show signs of ischemia in patients presenting to the ED with chest pain.  All patients who sought medical attention for chest pain and had at least one hs-cTnT analyzed during two years at the Karolinska University Hospital, Stockholm, Sweden, were included.  They calculated the negative predictive values of an undetectable hs-cTnT and EKG without ischemia for MI and death within 30 days.  The negative predictive value for MI within 30 days in patients with undetectable hs-cTnT and no ischemic EKG changes was 99.8% (95% confidence interval [CI]: 99.7 to 99.9).  The negative predictive value for death was 100% (95% CI: 99.9 to 100).  They conclude that all patients with chest pain who have an initial hs-cTnT level of less than 5 nanograms per liter (ng/L) and no signs of ischemia on an EKG have a minimal risk of MI or death within 30 days, and can be safely discharged directly from the ED.

Multiple observation protocols have been developed, which have been shown to be safe and deliver effective care.  Studies report that over one third of hospitals have implemented an ED observation unit.

This patient presented to the ED with a complaint of chest pain.  The patient's troponins were negative and his EKG showed no ST segment changes consistent with myocardial injury.  Literature recognizes the use of an observation unit for this type of patient.  
The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial should be upheld.