Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac symptoms

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a female with a past medical history of palpitations. She had been diagnosed with having symptomatic atrial fibrillation in the past and now presents to the ED after experiencing left arm and forearm pain for one hour accompanied by chest tightness, dizziness, nausea and one episode of vomiting. She denies previous presence of similar symptoms but did describe experiencing weakness for several days a couple of years prior.  Her family history reveals that both parents have diabetes mellitus and another family member has hypertension. The record indicates that the patient was admitted to the hospital and monitored on telemetry. A note written stated that the patient was doing well that morning, however she had three episodes of pressure like chest pain last night, each radiating to her left arm and lasting for approximately 30-45 minutes. She did not inform anyone of this complaint and therefore no documented EKG is available. An electrocardiogram (EKG) was performed on a subsequent day and this showed normal sinus rhythm at 68 bpm with one ventricular premature beat noted. The Echocardiogram was done and showed that the left ventricular size was normal with normal systolic function and ejection fraction estimated to be 58% with no regional wall motion abnormalities.

Since admission she has experienced approximately five 30-60 minute-long episodes of symptomatic arrhythmia which was accompanied by 2/10 chest pressure and 3/10 left upper extremity pain which wakes her at night. The chest x-ray was unremarkable. The EKG showed frequent ventricular premature beats (VPB's) in a bigeminal pattern. The patient was medically stabilized and discharged home with plans in place for outpatient follow-up.
High-sensitivity cardiac troponin T (hs-cTnT) have 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.(4) 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.
Many patients admitted to the hospital with cardiorespiratory and other acute syndromes are placed on electrocardiographic monitoring. Although electrocardiographic monitoring (ECGM) has advantages and is undoubtedly invaluable in certain patients, significant overuse of cardiac telemetry monitoring does occur.  The impact of this inappropriate use increases the cost of healthcare and can delay the admission process, an unpleasant burden which the hospital and its patients must bear.  
She also had a chest x-ray that was within normal limits and echocardiogram which showed no wall motion abnormalities. 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 that this reviewer has cited shows that a monitored level of care for this patient was not necessary or appropriate. The health plan acted reasonably and with sound medical judgment and in the best interest of the patient.
Therefore, the denial of coverage for the inpatient admission (telemetry) should be upheld. The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.