Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Coronary Syndrome
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission 
The denial is upheld 

This an adult patient that presented to the hospital with complaints of generalized weakness. Past medical history included hypertension, diabetes mellitus, chronic kidney disease, paroxysmal atrial fibrillation, sick sinus syndrome requiring permanent pacemaker and below the knee amputation. Upon arrival to the hospital vital signs were stable: Blood pressure 121/76, and pulse 60. Physical examination revealed 2 plus pitting edema of the right lower extremity up to the knee. 12 lead electrocardiogram (EKG) revealed normal sinus rhythm with a paced rhythm. Serum blood testing demonstrated an elevated creatinine of 1.7 milligrams per deciliter (mg/dl) and an elevated troponin level of 0.11 nanograms per milliliter (ng/ml). The patient was admitted to the hospital for monitoring and treatment. Echocardiogram revealed left ventricular hypertrophy with a preserved left ventricular ejection fraction (LVEF). Troponin levels trended downward immediately. The patient was treated with diuretic therapy and discharged home.

The health plan acted reasonably and with sound medical judgment and in the best interest of the patient. Inpatient hospital admission was not necessary for this patient that presented with weakness. The pretest probability of coronary artery disease is intermediate. (Reference 1) Utilizing the HEART (History, EKG, Age, Risk factors, and troponin) score, the patient was considered intermediate risk. (Reference 2) Risk assessment of patients presenting with non-ST elevation myocardial infarction was reviewed by Hedayati et al. (Reference 3) Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events [defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. These findings are concerning and warrant management and evaluation that includes serial troponin measurement, echocardiography and ischemia work up prior to discharge. However, numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care. (References 4,5) They found no significant difference in outcome at 30 days between the two groups. Fernando Bellolio et al. noted that patients presenting with chest pain, that were managed in an observation unit, had similar 30-day myocardial infarction rates as those admitted to the hospital. (Reference 5) Admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been managed at a lower level of care.

Based on the above, the insurer's denial must be upheld. The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital admission is not substantiated.