Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain.

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 diabetes mellitus, hypertension and hyperlipidemia who presented to the Emergency Department (ED) with chest pain. Chest pain occurred while at rest and radiated to the left neck. Pain lasted for one hour and resolved spontaneously prior to arrival at the ED. On arrival to the ED vital signs were stable [pulse 91 beats per minute (bpm), blood pressure (BP) 144/80] and physical exam was within normal limits. Electrocardiogram revealed findings that were unchanged from previous electrocardiograms. Serial serum troponin level were not elevated. An echocardiogram revealed a preserved left ventricular ejection fraction (LVEF) of 55% without wall motion abnormalities. The patient reported that stress testing was performed several months earlier and results demonstrated no abnormality. Computed tomography (CT) angiogram was performed and revealed left anterior descending (LAD) lesion that was 60-80%. Cardiac catheterization was performed and revealed non obstructive coronary artery disease with a 20% proximal lesion of the LAD artery. No intervention was necessary and the patient was discharged on medical therapy.

Inpatient hospital admission was not medically necessary for this patient who presented with chest pain. His pretest probability of coronary artery disease is intermediate. (1) Utilizing the HEART (History, Electrocardiogram, Age, Risk factors, Troponin) score he was considered intermediate risk.(2) Risk assessment of patients presenting with chest pain and no significant ST segment changes on Electrocardiogram was reviewed by Hedayati et al. (Reference 3). Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. These findings are concerning and warrant management and evaluation that includes serial troponin measurement; echocardiography and ischemia work up prior to discharge. However, numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care.(4,5) They found no significant difference in outcome at 30 days between the two groups. 

Fernando Bellolio et al. noted that patients presenting with chest pain, that were managed in an observation unit, had similar 30 day myocardial infarction rates as those admitted to the hospital.(5) This patient had already undergone nuclear stress testing prior to admission and no abnormalities were found. Admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been managed at a lower level of care.

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

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