Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain.

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient admission.

The denial is upheld. 

This male patient has a history of diabetes mellitus (DM) and major depressive disorder. The patient presented to the Emergency Department (ED) for referral to psychiatry. The patient reported having increased depression for 3 weeks. The patient's electrocardiogram (EKG) was interpreted as normal. 
 
The patient reported that for the past month he had been having exertional left-sided chest pain with palpitations that were relieved with rest. A nurse practitioner (NP) noted there was no emergent psychiatric complaint requiring psychiatric consultation. They transitioned the patient to the main ED for further evaluation of his palpitations and associated hyperglycemia. The patient's was a former user of cigarettes and alcohol. Troponin was within normal limits. A nuclear stress test showed no abnormalities. An echocardiogram showed left ventricular ejection fraction (LVEF) of 62%. 

The patient was pain-free at admission and had no events while on telemetry. The patient's electrocardiogram (EKG) was unremarkable with a negative troponin; the plan was to do serial EKGs and troponins and follow-up with cardiology. For his DM, the plan was to treat the patient with the sliding scale of insulin and resume the patient's oral medications as an outpatient.

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 ED with chest pain (4). All patients who sought medical attention for chest pain and had at least 1 hs-cTnT analyzed during 2 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 <5 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. 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 are one of the most prominent groups of such patients (5). 

This patient presented to the hospital with a complaint of chest pain, palpitations and shortness of breath when walking one avenue block. The patient had DM and had been off of his diabetic medications for one year. The patient also had significant problems with depression. The patient's troponin x1 was within normal limits and his EKG was within normal limits. The literature supports that this patient would have been an appropriate candidate for an observation unit since he had no troponin elevations and had a normal EKG.  The patient's care could have been safely provided at an observational level of care. Thus, inpatient hospital admission was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and 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 should be upheld.