Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain 
 
Treatment: Inpatient Admission 

The insurer denied the inpatient admission. The denial was upheld. 

This is a male patient with a history of coronary artery disease (CAD) with percutaneous coronary intervention (PCI) several years earlier, hypercholesterolemia and diabetes mellitus type 2. He presented to the emergency department (ED) with complaints of left sided shoulder/neck pain for 40 minutes after carrying a heavy back pack. Upon presentation to the ED he denied chest pain or shortness of breath. His initial troponin level was within normal limits. He was given Plavix 600 mg and an intravenous Heparin drip was planned but the patient refused. He was admitted to the hospital to telemetry for further monitoring. An electrocardiogram (EKG) was performed which revealed normal sinus rhythm with possible ischemic changes. A chest x-ray was done revealing clear lungs. A myocardial perfusion scan was performed with no perfusion defects and no evidence of ischemic dilatation of the left ventricle; ejection fraction was between 52-53%. An echocardiogram was performed which showed left ventricle was normal in size, wall thickness and systolic function with the calculated ejection fraction of 59%. There were no regional wall motion abnormalities seen and there was normal left ventricular (LV) diastolic function. A nuclear stress test showed that myocardial perfusion imaging was normal and left ventricular systolic function was normal without regional wall motion abnormalities. 

Many patients admitted to the hospital with cardiorespiratory and other acute syndromes are placed on electrocardiographic monitoring. Such electrocardiographic surveillance theoretically allows the clinical staff to monitor admitted patients for the development of dysrhythmia, both brady and tachydysrhythmia in essence, identify patient decompensation and/or clinical deterioration as it occurs rather than after the event. Electrocardiographic monitoring, also known as telemetry monitoring or cardiac monitoring, focuses on the detection of clinically significant dysrhythmia, rather than the diagnosis of acute coronary syndrome (ACS) or acute pulmonary edema. Although electrocardiographic monitoring (ECGM) has advantages and is undoubtedly invaluable in certain patients, significant overuse of cardiac telemetry monitoring does occur. The impact of this inappropriate use can delay the admission process, an unpleasant burden which the hospital and its patients must bear. In addition, the liberal use of monitoring in unnecessary situations may give the hospital staff a false sense of security and/or desensitize them to alarms. In many instances, electrocardiographic monitoring may not be necessary.(5)

A 2010 study showed that almost all (98.9%) patients with an indication for arrhythmia monitoring were being monitored. However, 84.9% of patients without an indication for arrhythmia monitoring were also being monitored. Of the patients with an indication for ischemia monitoring, 34.5% were being continuously monitored for ST-segment changes; but 26.3% of patients without an indication for ischemia monitoring were also being monitored for ST-segment changes. Only 21.4% of the patients with an indication for monitoring for QT prolongation had a QTc value documented by nurses in the previous 24 hours. However, 18.1% of patients with no indication for QT monitoring also had a QTc value documented. The observation that there is over monitoring for arrhythmias could be related to leaving patients on the monitor longer than necessary. Physicians may order monitoring because the patient who may have no risk for arrhythmias will be watched more closely primarily because of the increased nurse to patient ratios on units with ECG monitoring. In addition, once a patient is admitted to an Intensive Care Unit [ICU] bed, ECG monitoring is usually automatically initiated. It could be deemed inappropriate to have a patient in the ICU without the bedside ECG monitor on, regardless of the admitting diagnosis. (6) 

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest. 

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.