Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and shortness of breath.
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This is a male patient who went to the hospital complaining of chest pressure. His past medical history includes atrial fibrillation, hypertension, hyperlipidemia and diabetes mellitus. He complained of sharp chest pain which radiated down his left arm. This was accompanied with mild shortness of breath. An electrocardiogram (EKG/ ECG) showed normal sinus rhythm and was a normal EKG. He had a pharmacologic stress test done and no EKG abnormalities were noted after stress. A transthoracic echocardiogram was done and the conclusions were trace mitral regurgitation (MR), trace atrial regurgitation (AR), normal left ventricular (LV) internal dimensions and wall thickness, normal left ventricular systolic function and normal right ventricular size and function. His troponin levels were within normal limits. His N-terminal pro b-type natriuretic peptide (NT-proBNP) was also within normal limits. His chest X-ray showed no evidence of pneumothorax or pleural effusion. There were advanced arthritic changes of the left shoulder joint. The impression was no active pulmonary disease. A medical attending follow-up note written on day 2 of admission stated that the patient was stable for discharge and will be followed by his primary medical doctor (PMD) and cardiology as an outpatient. 

High-sensitivity cardiac troponin T (hs-cTnT) have been introduced as a highly sensitive and early biomarker of myocardial damage.(1) In two 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). (2, 3) A 2014 study from Sweden evaluated the significance of undetectable troponin levels and EKGs which did not show signs of ischemia in patients presenting to the Emergency Department [ED] with chest pain.(4) 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 ECG 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 ECG 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 <5 ng/l [nanograms per liter] and no signs of ischemia on an ECG have a minimal risk of MI or death within 30 days, and can be safely discharged directly from the ED.

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 ED observation unit.

This patient presented to the ED with a complaint of chest pain and shortness of breath that had been present for several hours. His troponins were negative and his EKG was normal. He had a nuclear stress test and an echocardiogram which showed no abnormalities. He was placed in a telemetry unit at the time of his admission. 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 that has been cited shows that a monitored level of care for this patient was not necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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