Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female with history of myasthenia gravis, fibromyalgia and POTS (postural orthostatic tachycardia syndrome). She was sent to the ER (emergency room) from urgent care due to continued severe left chest pain despite aspirin 324 mg (milligrams) and SL (sublingual) nitroglycerin. She had abnormal EKG (electrocardiogram) showing T-wave inversion in lead V1 to lead V4 (anterior ventricle).

In the ER (emergency room), the patient's chest pain persisted despite IV (intravenous) Toradol and Pepcid. She was monitored in clinical decision unit (CDU), where she had two negative serial cardiac enzymes. Subsequently, she was admitted in telemetry as inpatient to rule out acute coronary syndrome and for possible cardiac catheterization.

Following admission, the patient required SL (sublingual) nitroglycerin that improved her chest pain, but she developed headache. Cardiology evaluated the patient next day, identified chronic nature of T-wave inversion V1-V4 (anterior ventricle), and diagnosed her with atypical chest pain presentation. Cardiology was able to subsequently identify prior records for this patient with stress test and echo done in the prior year. Patient underwent echo during this hospitalization that showed normal LV (left ventricle) function and wall motion. Eventually, patient was discharged with close outpatient follow-up.

The health plan denied coverage of the inpatient admission on the basis that it was not medically necessary. The treating facility appealed this decision, contending that the admission was medically necessary.

Yes, the inpatient admission was medically necessary.

The initial chest pain presentation refractory to SL (sublingual) nitroglycerin raises concern for possible unstable angina, thus suggesting definite/possible ACS (acute coronary syndrome). At the time of information available to make decision regarding admission, the patient's TIMI (thrombolysis in myocardial infarction) risk score was 2 based on concerning possible unstable angina and abnormal electrocardiogram.

Per ACC (American College of Cardiology) guidelines, "The standard of care for patients who present with possible NSTE-ACS (nonST-segment [flat, isoelectric section of the ECG] elevation myocardial infarction-acute coronary syndrome), including those with recurrent symptoms, ischemic electrocardiographic changes, or positive cardiac troponins, is admission for inpatient management". Given abnormal EKG (electrocardiogram) changes on presentation, there was high likelihood of abnormal cardiac catheter that would have warranted intervention with either percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). This could have resulted in likely anticipated hospital stay more than 48 hrs. It is therefore appropriate for inpatient admission based on available information on patient's presentation. Based on admission TIMI (thrombolysis in myocardial infarction) risk score, patient has 8% (percent) risk at 14 days of: all-cause mortality, new or recurrent MI (myocardial infarction), or severe recurrent ischemia requiring urgent revascularization. Based on American College of Cardiology and the American Heart Association guidelines for ACS, early invasive risk strategy with coronary angiography is recommended in definite/possible ACS patients with TIMI score greater than or equal to 2 or EKG changes. Therefore, this patient was admitted for possible cardiac catheter and the inpatient stay was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.