Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department (ED) with chest pain. She described the chest pain as substernal chest pressure and tightness, intermittent, radiating to left arm. The severity was 6-8/10. She also was complaining of shortness of breath. The patient had a history of chest pain and a cardiology work up in the past was negative. Her previous echocardiogram had been unremarkable and a stress test was normal.

Her past medical history (PMH) includes a transient ischemic attack (TIA) versus complex migraine. She also has a history of anxiety. In the ED, her vital signs were stable. She was tachycardic with a heart rate (HR) up to 108. Her physical examination was unremarkable.

Her initial troponin was 0.06. Her electrocardiogram (ECG) was normal. A chest x-ray (CXR) was unremarkable. The patient was treated with aspirin, Toradol and nitroglycerin. She was admitted to the hospital and had a cardiology consult.

Initially, cardiac catheterization was recommended. However, it was changed to a noninvasive approach. The patient underwent cardiac magnetic resonance imaging (MRI) with gadolinium and it was negative for an infarct. Her coronary computed tomography angiography (CCTA) revealed negative coronary arteries. The patient's condition remained stable.

She was complaining on chest pain on and off and described it as chest pressure in the left side of her chest. A repeated ECG did not reveal any changes. Her telemetry revealed sinus rhythm and tachycardia up to 120 beats per minute (BPM). Repeat troponin in series was normal. The patient was discharged home. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.

The patient presented with recurrent chest pain, with minimal coronary risk factors. Her chest pain was worked up previously. Her presentation was similar and the only difference was the troponin value, which was minimally elevated. A repeat serial troponin was normal. The single troponin (which could be a lab error) prompted a cardiac MRI, computed tomography (CT) coronary angiography, serial troponins and ECG. All tests were negative, beside the first troponin. The patient's condition did not meet criteria for an inpatient admission. She could have been treated at a lower level of care.

As per the first reference below [1]: "As indicated in the Third Universal Definition of Myocardial Infarction consensus document, published in 2012, acute myocardial infarction (AMI) is defined by the detection of a rise and/or fall of cardiac biomarkers (preferably cardiac troponin levels) with at least 1 value above the 99th percentile upper reference limit and with at least one of the following: (a) symptoms of ischemia; (b) new or presumed new significant ST-segment-T wave changes or new left bundle branch block; (c) development of pathological Q waves in the electrocardiogram (ECG); (d) imaging evidence of new loss of viable myocardium or new regional wall motion abnormality; (e) identification of an intracoronary thrombus by angiography or autopsy. The Third Universal Definition of Myocardial Infarction consensus document, published in 2012, classifies MI (acute myocardial infarction) into 5 types, based on pathological, clinical, and prognostic differences, along with different treatment strategies. The performance and quality measures described in the current document are predominantly pertinent to patients with spontaneous MI, or MI type 1. MI type 1 is an event related to atherosclerotic plaque disruption (eg, rupture, ulceration, erosion) with superimposed thrombus formation in a coronary artery, resulting in acute reduction in myocardial blood supply and/or distal embolization with subsequent myonecrosis. MI type 2 is myocardial injury caused by conditions other than coronary artery disease that results in an imbalance between myocardial oxygen supply and/or demand (eg, coronary artery embolism or spasm, tachyarrhythmias, anemia, respiratory failure, profound hypotension)."