Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld 
 
This is an adult with a past medical history which includes hypertension, diabetes mellitus, hyperlipidemia, chronic obstructive pulmonary disease (COPD), coronary artery disease (managed medically after non-obstructive disease on left heart catheterization), tobacco abuse, and anxiety. She presented to Montefiore Hospital's emergency department (ED) with 3 weeks of intermittent chest pain radiating to the left arm, as well as numbness and tingling in the left arm. Shortness of breath was also noted.

The workup in the ED was reassuring for the absence of an acute process, with normal urinalysis, chest X-ray, CK (creatine kinase), troponin, D-dimer, and B-type Natriuretic Peptide (BNP). Borderline leukocytosis was non-specific and not concerning for active infection. Admission was for serial troponins, electrocardiogram (EKG), echocardiogram, and cardiology consultation.

The primary diagnoses at the time of admission were COPD and chest pain. The patient reported that she had quit smoking 1 month prior to admission. Bilateral pitting edema was noted. The plan included telemetry, troponins, echocardiogram, cardiology consultation, Thyroid stimulating hormone (TSH), aspirin, continue atorvastatin, consider coronary computed tomography angiogram (CCTA), continue Symbicort, albuterol nebulizer, prednisone, continue enalapril, manage blood sugars with home medications and lispro as needed. The elevated lactate was attributed to mild dehydration.

Chest X-ray was essentially normal. An echocardiogram showed normal left ventricular function with ejection fraction of 55%. Valvular function was normal. There was no pericardial effusion.

Nursing notes indicate no chest pain nor shortness of breath on room air.

Computed tomography angiography (CTA) of the coronary arteries showed mild (24-49%) stenosis of all of the major coronary arteries. The coronary calcium score was reported as high, with total Agatston score of 558, placing the patient in the 99th percentile for age, gender, and race.

The patient was discharged on aspirin and outpatient cardiology follow-up was recommended. COPD exacerbation was treated; prednisone, Trelegy, smoking cessation, and outpatient pulmonology follow-up were recommended.

In the ED, her HEART [history, ECG (electrocardiogram), age, risk factors, troponin] score was calculated. This score has been clinically validated and is described as "an internationally accepted risk stratification tool." The patient had a HEART score of 5. This score is considered moderate risk and associated with a 12-17% likelihood of MACE (major adverse cardiac event) over the following six weeks and would have led to a recommendation for "the potential consideration of observation and further testing."

According to the nursing notes, the patient was asymptomatic within 24 hours of arrival, and no longer experiencing shortness of breath nor chest pain. She had "ruled out" for myocardial infarction (MI) within hours of her arrival. All of her subsequent testing was reassuring. 

The possibility of COPD exacerbation was also considered and appears to have been the primary condition receiving active treatment during this hospitalization. Again, some form of admission was warranted in this context, as well, as per the UpToDate algorithm. However, in both cases, outpatient treatment would have been appropriate. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.