Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

 
This case involves an adult who presented to the emergency department with complaints of chest pain for 5 days with reports of 5 months of increasing shortness of breath.  She had a past medical history significant for coronary artery disease, obesity, and valvular heart disease.  The patient stated that her chest pain worsened with movement, and she was unable to go upstairs or exert herself due to the shortness of breath.  She described having a pressure-like pain that was moderate in intensity localized to the center of the chest with no radiation.  A recent echocardiogram revealed a normal functioning of biological tricuspid prosthesis with ejection fraction of 65% (percent).  Given prior findings of tricuspid valve (TV) leaflet thrombosis and consequent TV gradient, she was on warfarin.  On initial assessment, the patient's blood pressure was 147/101 with a pulse of 82, normal temperature and respirations 18.  Her body mass index was 40.63.  During the physical examination, a systolic murmur was heard during cardiovascular assessment.  There is no jugular vein distention appreciated and no peripheral edema appreciated.  The patient recently had a clot in her replacement valve for which she was treated with catheter and stenting and placed on Coumadin.  Her electrocardiogram (EKG) showed normal rate and sinus rhythm with right QRS axis, wide QRS intervals, and right bundle branch block (RBBB) conduction.  There were abnormal Q waves present but normal T waves and normal ST segments.  She received a HEART (risk score) score of 4 indicating a 12-16.6% risk of adverse cardiac event.  Laboratory values noted that prothrombin time was elevated at 28.5 and international normalized ratio (INR) was elevated at 2.6.  She had elevated carbon dioxide (PCO2) at 54.70, low oxygen (PO2) at 19, elevated bicarbonate (HCO3) at 29, low total hemoglobin at 10.2, elevated methemoglobin at 1.8, low venous oxygen saturation at 28, low venous hematocrit at 31.6, low white blood cell count at 4.0, low mean corpuscular hemoglobin concentrates at 32.4, low neutrophil count at 1.7, elevated lymphocytes at 46, elevated reactive lymphocyte at 3, with glucose low at 68, and low anion gap at 6.  

According to the Milliman Care Guidelines, the goal length of stay for the patient having chest pain is 1 day.  Clinical indications for admission to inpatient care include those who are hemodynamically unstable, those in respiratory distress, when there is chest pain indicative of serious diagnosis other than coronary artery disease to include aortic dissection or pulmonary embolism, and severe pain requiring acute inpatient management.  Alternatives to inpatient admission include observation, office, or outpatient care.  

While it was noted that the patient had a history of obesity, coronary artery disease, and valvular heart disease, the evidence did not suggest that the patient's care could have been safely and effectively managed on an observational basis.  She did not have any significant findings on diagnostic imaging, and while there were some abnormalities noted on laboratory testing, these were not in the critical ranges and could have been monitored without the patient needing inpatient treatment.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is not substantiated.