Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission. 
The denial is overturned in part.

The patient is a male who presented to the emergency department complaining of chest pain, subjective fever, decreased appetite, nausea and generalized weakness. His medical history was remarkable for chronic obstructive pulmonary disease (COPD), diabetes, hyperlipidemia, hypertension and substance abuse. His blood pressure was 146/78 millimeters of mercury (mmHg) with a heart rate of 72 beats/minute. His respiratory rate was 20/minute with a room air oxygen saturation of 100%. He was afebrile. An electrocardiogram showed sinus rhythm with right bundle branch block, new anterior ST segment depression compared to prior tracings and lateral T wave inversions. Chest x-ray showed no acute pathology. The patient's serum troponin level was elevated at .112 nanogram per milliliter (ng/ml). His N-terminal pro brain natriuretic peptide (BNP) level was 628 picograms per milliliter (pg/ml). Urine toxicology was positive for cocaine and cannabinoids. A nasopharyngeal swab was sent for testing for SARS-CoV-2. The patient was treated with aspirin and admitted to the hospital. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned in part.

The inpatient hospital admission was medically necessary in part.
This patient, who had recently used cocaine, presented with chest pain, new ischemic electrocardiographic changes and positive cardiac biomarkers, all of which suggested acute coronary syndrome.
Cocaine exerts multiple effects on the cardiovascular system, including coronary vasoconstriction, platelet aggregation and increased metabolic demand, all of which may precipitate acute coronary syndrome (ACS). The presence of myocardial ischemia potentiates the risk of cocaine-associated arrhythmias. In patients with cocaine-associated chest pain, the presence of elevated cardiac biomarkers has been shown to be associated with an increased the risk of the composite end point of all-cause mortality, myocardial infarction and the need for revascularization. According to the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, "Acute coronary syndrome in patients with a history of cocaine use should be treated in the same manner as patients without cocaine use." Per this document, patients with a diagnosis of ACS based on symptoms and electrocardiographic and biomarker criteria warrant inpatient care. Thus, given this man's chest pain, ischemic electrocardiographic changes and elevated cardiac biomarkers, diagnostic criteria for ACS were met. An inpatient level of care was medically necessary in part. Cardiac catheterization had been performed and showed no obstructive disease, the patient had no further chest pain, and his serum troponin level was decreasing. Despite his COVID-19 diagnosis, he had no respiratory complaints and normal arterial oxygen saturation.
From a cardiac standpoint he would have been stable for discharge at that point. However, he remained hospitalized while arrangements for his quarantining in a hotel were made. This did not require an inpatient level of care. Current Centers for Disease Control and Prevention (CDC) guidelines for the treatment of patients with COVID-19, indicate that patients with mild to moderate disease, and no evidence of hypoxia or pneumonia, do not require hospitalization.