Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain. 
Treatment: Inpatient admission. 

The insurer denied coverage for an inpatient admission. 

The denial is overturned. 

This is an adult who presented to the emergency department (ED) with chest pain. His past medical history included tobacco abuse and migraines. He reported 1 week of worsening intermittent 7/10 chest pain, with radiation to the left arm, and with shortness of breath with trivial activity (taking a few steps). He reported orthopnea. His electrocardiogram (EKG) was abnormal. His brain natriuretic peptide (BNP) was elevated at 4,833, and troponin rose from 62.31 to 116.50. The chest X-ray (CXR) showed interstitial edema with cardiomegaly. The D-dimer was elevated, but the lower extremity doppler was negative for deep vein thrombosis (DVT). He was admitted with a diagnoses of non-ST (interval on an ECG)-elevation myocardial infarction (NSTEMI) and heart failure, unspecified. Soon thereafter, he signed out against medical advice (AMA) after being advised of the associated risk. His HEART (a cardiac risk calculation) score was calculated as 5. 

The patient reported a prior cardiac catheterization years earlier which revealed that "his heart was pumping at 34% (percent)" (presumably representing a left ventricle (LV) ejection fraction of 34%). He had followed with a cardiologist in the past but stopped going because he felt the "blood pressure medications" he was being prescribed were unnecessary. He had previously been treated with an appropriate heart failure (HF) regimen including Entresto, carvedilol, and Lasix. There was a recent pneumonia noted, which had been treated with antibiotics. The treating physician felt the chest pain represented NSTEMI (a type of heart attack) vs (versus) demand ischemia and that stress testing or cardiac catheterization were likely to be needed. A cardiology consultation, aspirin, an echocardiogram, and additional troponins were ordered. 

The admission was appropriate given the severity of presentation, with rising troponin suggestive of a primary NSTEMI, or alternatively with heart failure associated with a Type-2 myocardial infarction (MI). Either of these findings met the Milliman Care Guide (MCG) criteria. 

In support of that decision, a HEART score was calculated in the ED to help determine if further observation was appropriate. This score has been clinically validated and is described as "an internationally accepted risk stratification tool." The patient had a HEART score of 5 (2 points for history, one for risk factors, one for age, and one for ECG with none for troponin). While that score would have risen to 6 with the second troponin, that would not have increased his risk category. Either score would be considered moderate risk and associated with a 12-17% likelihood of MACE (major adverse cardiac event) over the following six weeks and would have led to a recommendation for "the potential consideration of observation and further testing."

Inpatient admission was medically necessary for the patient, for the reasons outlined above. He was experiencing unstable and progressive chest pain, had multiple factors indicating active coronary disease, and was being appropriately treated with admission for aggressive workup. His cardiac risk was high. Factors supporting that risk included his ECG abnormalities, elevated and rising troponin, elevated BNP, progressive exercise intolerance, history of cardiomyopathy, active tobacco abuse, and medication non-compliance. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital admission is substantiated.