Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.

Treatment inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This patient has a past medical history which includes hyperlipidemia, hypertension, left ventricular hypertrophy, anemia, nephrolithiasis, and deep vein thrombosis (DVT). She presented to the emergency department (ED) with 10 days of chest pain. She was ultimately discharged to home. Her initial workup in the ED and subsequent inpatient workup were largely unremarkable other than an incidental finding of bulky uterine fibroids.

 Physician noted 10 days of chest pain radiating to the back, getting progressively worse, with mild dyspnea and worsening left lower extremity pain for two weeks. She had seen her cardiologist earlier in the day that "rule patient out for MI [myocardial infarction] and admit, rule out DVT [deep vein thrombosis] pulmonary embolism (PE) and pancreatic disease" (due to elevated lipase). The patient was already taking apixaban (Eliquis) 5mg (milligrams) twice daily (BID). Electrocardiogram (EKG) showed pseudonormalization of inferior and precordial T (interval on EKG) wave inversions when compared to prior EKG. Lab work, exam, and vital signs in the ED were unremarkable. The plan focused on chest pain, with plans check a second troponin, follow echo, continue home meds, and admit.

The health plan acted reasonably and with sound medical judgment and in the best interest of the patient. The patient presented with chest pain and does have risk factors for coronary artery disease, including hypertension, hyperlipidemia, and diabetes mellitus; the initial emergency department workup was therefore appropriate, as was indicated in the Uptodate. However, once that workup was completed, there was no further indication for hospitalization, particularly under inpatient status. It appears that she remained in the hospital during the final 3 days of her hospitalization for the purpose of performing a stress test after the weekend. However, her cardiologist had already indicated this testing could be performed as an outpatient, given the otherwise reassuring workup. There is no reason in the submitted documentation which indicates why that stress test was not performed on the second day in the hospital.

Her HEART (history, EKG, age, risk factors, troponin) Score was 3 and 3 risk factors. This puts her at low risk, indicating that an expedited workup without need for admission is appropriate. This score has been validated multiple times, including analyses comparing it favorably to other methods of risk evaluation.

Two troponins were adequate to exclude myocardial infarction and to confirm her low risk of adverse events in the setting of atypical chest pain.The atypical nature of the patient's pain was documented multiple times. The use of echocardiography for her persistent pain increased confidence, improving both the sensitivity and the specificity of her diagnosis of non-cardiac pain.

The inpatient hospital admission was not medically necessary for the patient. The low-risk presentation of atypical chest pain was effectively and appropriately evaluated in the emergency department, after which only outpatient follow-up was needed. This is consistent with the documentation submitted for review, in which this conclusion is plainly stated.
The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.