Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This woman presented to the emergency room (ED) complaining of one month of intermittent chest pain. For the prior three days, the chest pain was associated with near syncope. Her medical history was remarkable for hypertension, hyperlipidemia and morbid obesity. Her blood pressure was 119/59 mmHg with a heart rate of 73 beats/minute. Her room air oxygen saturation was 100%. On physical exam, she had point tenderness in the left parasternal region. Her electrocardiogram showed sinus rhythm without acute ischemic changes. Chest X-ray and head computed tomography (CT) scan showed no acute pathology. The patient was treated with aspirin and ketorolac and was admitted to the hospital. 

The inpatient hospital admission was not medically necessary.
This woman presented with atypical symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. On the other hand, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. Based on her HEART score she was at low risk for major adverse cardiac events (0.9-1.7%). The care this patient received for her chest pain did not require an inpatient admission and could have been provided under "observation" status. This approach has been shown to be both safe and effective and is in accordance with the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Upon presentation, the patient also reported episodes of near syncope. She was hemodynamically stable, with normal cardiac biomarkers. Her electrocardiogram was unremarkable. The literature does not adequately describe which patients will benefit from inpatient hospital admission or observation nor has it demonstrated the value of admission in preventing future adverse outcomes. However, certain features have been identified as signifying high risk. These include exertional syncope, known structural heart disease, age > 60 years and a family history of sudden cardiac death. This patient had none of these features.
Per the 2017 ACC/AHA/ Heart Rhythm Society (HRS) Guideline for the Evaluation and Management of Patients With Syncope, inpatient admission is recommended for patients presenting with syncope who have a serious medical condition potentially relevant to the cause of syncope identified during initial evaluation. This patient had no such condition identified. The document further states, "In intermediate-risk patients with an unclear cause of syncope, use of a structured ED observation protocol can be effective in reducing hospital admission. Two small randomized controlled trials (RCTs) suggest that structured ED-based protocols, consisting of time-limited observation and expedited access to cardiac testing/consultation, result in reduced health service use without adverse impact on clinical outcomes when compared with unstructured hospital admission." Thus, based on the information provided an inpatient level of care was not medically necessary for evaluation of this patient's near syncopal spells.