Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out Acute Coronary Insufficiency (ACI). 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This is a male patient with a past medical history of hypertension, hyperlipidemia, asthma and multiple Emergency Room (ER) visits for chest pain.  He presented complaining of sudden onset of non-radiating, sharp, constant left sided pain that woke him from sleep. When he woke with pain, he also had multiple episodes of nausea and vomiting.  He noted dizziness which prompted him to call Emergency Medical Services (EMS) to bring him to the ER.  He complained of upper abdominal pain.  The patient described the abdominal pain, which first started in the right lower quadrant (RLQ), as sharp and constant with no radiation.  This was shortly followed by left sided chest pain that was also described as sharp and constant with no radiation.  Pain was made worse with shifting positions.   Several hours after onset of abdominal and chest pain the patient developed nausea and began having episodes of vomiting.  On physical exam he was described as being overweight.  There was abdominal tenderness in the right upper quadrant and epigastric area. No other abnormalities were noted.  His physician stated that given the patient's cardiac risk factors they will admit the patient to telemetry to rule out Acute Coronary Insufficiency (ACI). 

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 [electrocardiograms] which did not show signs of ischemia in patients presenting to the Emergency Department 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 myocardial infarction (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 [nanograms per liter] 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.  Recognizing the value of an Observation Unit, studies report that over one third of hospitals now have implemented an ED observation unit.(5,6) 

This patient was placed in a telemetry unit at the time of admission, which was medically necessary.  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 cited shows that a monitored level of care for this patient was not medically necessary. 

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

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.