Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Full hospital admission

The insurer denied coverage for the full hospital admission.

The denial is upheld.

This is a male patient who came to the hospital complaining of chest pain and dysphagia for 1 week. The patient's past medical history includes diabetes mellitus, hypertension, hyperlipidemia, obesity, and chronic obstructive pulmonary disease (COPD). He reported that for the past week he has had intermittent left-sided chest pain described as pressure with no radiation. The pain was associated with shortness of breath and a feeling of inability to swallow. On physical examination, the patient was described as being obese and breathing comfortably on room air. There was a crescendo decrescendo murmur best heard at the right upper sternal border. There was chest pain which was reproducible on palpation; it was tender to the left axilla between the fifth and sixth rib. There was trace bilateral leg edema with the left being worse than the right. The patient's troponin levels, trended twice, were within normal limits. The patient's bilateral lower extremity venous duplex scan showed no evidence of abnormality. A Baker's cyst was visualized in the right lower extremity. The patient's chest pain was reproducible on palpation and he had no ischemic changes on his electrocardiogram (EKG). The patient's troponin levels were within normal limits and transesophageal echocardiogram showed no recent changes.  

High-sensitivity cardiac troponin T (hs-cTnT) has been introduced as a highly sensitive and early biomarker of myocardial damage. In 2 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 2014 study from Sweden evaluated the significance of undetectable troponin levels and electrocardiograms which did not show signs of ischemia in patients presenting to the Emergency Department (ED) with chest pain. 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 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.

Studies report that over one third of hospitals have implemented an ED observation unit. In this case, this patient presented to the ED with a complaint of chest pain that had been present for 1 week. The patient's troponin levels were within normal limits, which would not have been expected if the patient had acute coronary syndrome (ACS) for 1 week. The patient's chest pain was reproducible on palpation and he had no ischemic changes on his EKG. The patient's transesophageal echocardiogram showed no recent changes, and specifically no wall motion abnormalities. The literature recognizes the use of an observation unit for this type of patient. Thus, the full 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.

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