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 female patient who has polycystic kidney disease, hypertension and end-stage renal disease, who is pre-hemodialysis and has a left upper extremity fistula. She had an abnormal stress test and presented to the hospital with chest pressure that she experienced the day prior while cooking that was constant for 30 minutes and abated with rest. The patient's chest pain was described as being in the sub sternal area and did not radiate. It was described as a pressure moderate in severity. She rated the pain as 5/10 in intensity and claimed that it occurred with normal activity and was relieved with rest. 

No abnormalities are described on her physical exam. There is a family history of polycystic kidney disease, hypertension and diabetes mellitus. The disposition was that she should be admitted to telemetry with Nephrology and Cardiology consults pending. Echocardiogram showed severe left atrial (LA) dilatation, borderline left ventricle (LV) dilatation and mildly decreased left ventricular ejection fraction. The right atrium (RA) was normal in size and the right ventricle (RV) was normal in size with normal right ventricular (RV) function. There is mild atrial regurgitation (AR) and moderate mitral regurgitation (MR). There is minimal tricuspid regurgitation (TR). There is no evidence of pericardial effusion. 

Many patients admitted to the hospital with cardiorespiratory and other acute syndromes are placed on electrocardiographic monitoring. Such electrocardiographic surveillance theoretically allows the clinical staff to monitor admitted patients for the development of dysrhythmia, both brady- and tachydysrhythmia in essence, identify patient decompensation and/or clinical deterioration as it occurs rather than after the event. Electrocardiographic monitoring, also known as telemetry monitoring or cardiac monitoring, focuses on the detection of clinically significant dysrhythmia, rather than the diagnosis of acute coronary syndrome (ACS) or acute pulmonary edema. Although electrocardiographic monitoring has advantages and is undoubtedly invaluable in certain patients, significant overuse of cardiac telemetry monitoring does occur. The impact of this inappropriate use increases the cost of healthcare and can delay the admission process, an unpleasant burden which the hospital and its patients must bear. In addition, the liberal use of monitoring in unnecessary situations may give the hospital staff a false sense of security and/or desensitize them to alarms. In many instances, electrocardiographic monitoring may not be necessary (1).

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 Emergency Department (ED) observation unit (2,3). This patient presented to the ED with a complaint of chest pressure that lasted for 30 minutes and was relieved by rest. Her troponins were negative and her electrocardiogram (EKG) showed no ST segment (the flat, isoelectric section of the ECG between the end of the S wave and the beginning of the T wave) changes consistent with myocardial injury. She was placed in a telemetry unit at the time of this admission, while various consults were called. Inpatient hospital admission was not medically necessary. The 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 shows that a monitored level of care for this patient was not necessary, nor appropriate. 

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 inpatient hospital admission should be upheld. The medical necessity is not substantiated.