Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headaches.  
Treatment: Inpatient Hospital Admission.  
The insurer denied coverage for inpatient hospital admission.  
The denial is upheld.  

This gentleman presented to the hospital after his primary medical doctor (PMD) noted an abnormal echocardiogram (ECG).  The patient reported chest pain that was atypical in nature and a right sided headache.  Past medical history was significant for diabetes mellitus (DM) and hypertension (HTN).  ECG revealed normal sinus rhythm with a heart rate of 97 beats per minute (bpm), normal PR (intervals on ECG), QRS (intervals on ECG) and QT (intervals on ECG) intervals, poor R (intervals on ECG)  wave progression across the precordial leads and T (intervals on ECG) wave inversions in the inferior leads.  Serum troponin levels were not elevated twice (<0.010 ng/ml [nanogram per milliliter]).  Echocardiogram revealed a preserved left ventricular ejection fraction (LVEF) with no wall motion abnormalities and no valvular abnormalities.  Additional history documented in the medical record notes that the patient denied chest pain entirely and noted that the reason he presented to the Emergency Department (ED) was for headache.  Ultimately, the patient was seen by a Cardiologist that recommended an outpatient stress test.  Computed tomography (CT) and magnetic resonance imaging (MRI) of the head did not reveal any intracranial pathology.  

HEART [history, ECG anomalies, the patient's age, any risk factors present] score he was considered intermediate risk.(2) Risk assessment of patients presenting with chest pain and no significant ST changes on ECG 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, echocardiography and ischemia work up 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 myocardial infarction rates as those admitted to the hospital.(5)  Admission to the hospital to treat an acute cardiac event was not medically necessary.  In the case of this patient, a detailed history revealed that he really was not having any chest pain.  The cardiology consultant appropriately recommended an outpatient ischemia work up. In conclusion, this patient could have been managed at a lower level of care.  

The health plan acted reasonably and in the best interest of the patient.  Inpatient hospital admission was not necessary for this patient that presented with an abnormal ECG and headaches.   His pretest probability of coronary artery disease is intermediate.(1)  

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