Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chest pain

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is upheld

The patient presented to the hospital complaining of palpitations and chest pain.  Past medical history was significant for myocardial infarction, heart failure with a reduced ejection fraction 40-45%, hypertension and hyperlipidemia. Upon arrival, vital signs were stable (BP (blood pressure) was 114/71, pulse 86bpm (beats per minute). Physical examination was benign, and no abnormalities were reported. A 12 lead ECG (electrocardiogram) revealed normal sinus rhythm without ectopy and an old anterior wall infarct. There was no evidence of acute ischemic changes. Serum blood testing revealed no significant elevation in high sensitivity troponin (14.2ng (nanograms)/L (liter). The patient was admitted for monitoring and treatment. Telemetry revealed no evidence of arrhythmia and echocardiography revealed no change in LVEF (left ventricular ejection fraction).  The patient was treated with guideline directed medical therapy and discharged the following day.

Full hospital admission was not necessary for this patient who presented with chest pain and palpitations. His pretest probability of coronary artery disease is high. (Reference 1). Utilizing the HEART (history, ECG abnormalities, the patient's age, any risk factors present, and troponin) score, he was considered intermediate risk (5 points). (Reference 2) Risk assessment of patients presenting with chest pain and no significant ST (interval on an ECG) changes on an ECG 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 a work up can be performed in an observation unit without the need for a 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.

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 admission is upheld. Medical Necessity is not substantiated.