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 is the case of an adult male patient with a history of mixed ischemic/non ischemic cardiomyopathy and chronic systolic heart failure and a left ventricular ejection fraction (LVEF) of 15% (percent), that presented to the hospital with dyspnea, lightheadedness and chest tightness that continued for three hours following exertion. Additional past medical history included cardiac resynchronization therapy (CRT)- implantable cardioverter-defibrillator (ICD) in situ, paroxysmal atrial fibrillation (AF) and paroxysmal ventricular tachycardia with an appropriate ICD shock 3 weeks prior to admission with up titration of amiodarone. Upon arrival to the Emergency Department (ED), blood pressure (BP) was 131/86 and pulse was 69 beats per minute. Physical exam revealed no gross abnormalities and no signs of acute fluid overload. Electrocardiogram (EKG) revealed A sensed, V (intervals on EKG) paced rhythm and ICD interrogation revealed no rhythm abnormalities. Serum blood testing revealed an elevated B-type natriuretic peptide (BNP) (342 picograms/milliliter [pg/ml]) and no elevation in troponin (Tn) (Tn<0.012 nanograms/milliliters [ng/ml]). The patient's symptoms resolved without treatment, and he was discharged the following day.     

The patient's pretest probability of coronary artery disease is intermediate. (1) Utilizing the HEART (History, EKG, Age, Risk factors, and troponin) score he was considered intermediate risk. (2) Risk assessment of patients presenting with chest pain and no significant ST (intervals on EKG) changes on EKG was reviewed by Hedayati et al. (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 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. (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 MI rates as those admitted to the hospital. (5) 

This patient had no pertinent findings on physical examination to suggest decompensated heart failure and no elevation in Tn level. 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. Full hospital admission was not medically necessary for this patient that presented with chest pain.  

The health care plan did act reasonably, with sound clinical judgment, and 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.