Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out acute coronary syndrome; Chest Pain 
 
Treatment: Inpatient Admission 

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

This is a female patient with a medical history of hypertension, hyperlipidemia, diabetes mellitus, depression, chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD), and smoking cigarettes for several years.  She presented to the Emergency Department (ED) after being evaluated by her cardiologist due to an abnormal electrocardiogram while in his office.  She had complaints of fever, shortness of breath, and a cough for one week.  A laboratory work up included white blood cell (WBC) count 10.4, hematocrit 35.4, glucose 127, blood urea nitrogen (BUN) 19, creatinine 2.41 and sodium 142.  Her pro-BMPs were 389 and her initial troponin was within normal limits, with negative cardiac enzymes.  She had an Echocardiagram that showed an estimated ejection fraction of 55%, left ventricle was normal in size and systolic function was normal and mild to moderate mitral regurgitation (MR) there was mild tricuspid regurgitation (TR).  An electrocardiogram (EKG) was performed normal sinus rhythm with inverted T waves. She was monitored on telemetry.  She was started on intravenous steroids for an expiratory wheeze and productive cough.  She was medically stable and discharged home with instruction to follow up with outpatient magnetic resonance imaging (MRI) of the heart.  

High-sensitivity cardiac troponin T (hs-cTnT) have been introduced as a highly sensitive and early biomarker of myocardial damage.  In two prospective cohorts of patients admitted to the hospital for chest pain, undetectable hs-cTnT was found to have a very high negative predictive value for myocardial infarction (MI). (1,2)  

Multiple observation protocols have been developed which have been shown to be safe and deliver effective care.  Recognizing the value of an Observation Unit, studies report that over one third of hospitals now have implemented an ED observation unit. (6)  

This patient was directed to come to the ED because of diffuse T wave changes noted on her EKG.  She had reported intermittent non-exertional chest pain for the previous five days.  She also reported a cough and low-grade fever.  She has a past history of chronic kidney disease, diabetes mellitus, COPD and hypertension.  Her troponin values were negative and her EKG showed persistent T-wave changes with no interval change.  She was admitted to a telemetry unit to rule out acute coronary syndrome, which was unlikely because of her negative troponins and stable EKG.  An echocardiogram showed no regional wall motion abnormalities and normal left ventricular systolic function.  Her pulmonary consultant thought that the chest discomfort was likely secondary to exacerbation of COPD and recommended intravenous steroids and bronchodilators which relieved the patient's symptoms.  The health plan acted reasonably and with sound medical judgment in the best interest of the patient.  

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.