Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Coronary Artery Disease.
Inpatient Hospital Admission.
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a male who presented to the emergency department (ED) with chest pain. He described chest pain as pressure/squeezing and it was persistent after onset. The pain began the night before presentation while the patient was lying in bed and reading the book. The patient had previously suffered a non-segment (ST) elevation myocardial infarction (NSTEMI) and underwent placement of multiple stents. The patient reported that his pain feels similar to the pain he experienced during his myocardial infarction (MI).
In the ED, his vital signs were as follows: blood pressure (BP) 177/88, heart rate (HR) 89 beats per minute (BPM), and his peripheral capillary oxygen saturation (SpO2) was 97 percent (%). His physical examination was unremarkable. His lungs were clear and equal bilaterally. His heart was regular with normal sounds. His abdomen was soft, non-tender and non-distended. The neurological examination was intact. His initial troponin was negative.
His chest x-ray (CXR) was negative for acute cardiopulmonary disease. The electrocardiogram (ECG) revealed sinus rhythm with the rate of 83 BPM. After sublingual (S/L) nitroglycerin (NTG), his chest pain improved. The patient's case was presented over the phone to the cardiologist on call, and Lovenox, Plavix and statin was recommended.
The cardiology consultant noted that the patient has chest wall tenderness, reproducible on palpation. The pain was worse with moving shoulders and turning. The impression was that the pain is most likely musculoskeletal. Cardiology noted in the progress note, that the patient has chest wall tenderness, reproducible and chronic. Most likely the chest pain was due to costochondritis. They recommended treating it with Tylenol as needed (prn).
The cardiology consultant indicated that the patient has atypical chest pain, negative serial troponin, normal electrocardiogram (EKG), acute coronary syndrome (ACS) unlikely and no further cardiac work up indicated at this time. The patient can be discharged.

The patient has a history of coronary artery disease and previous coronary stents for NSTEMI, presented with chest pain. His troponin and ECG were negative. His vital signs and physical examination were unremarkable. The patient with non-cardiac chest pain, due to costochondritis, otherwise stable, did not have indications for inpatient admission. 

The paragraph below is from the first reference:
"The goals in patients presenting to the ED or office with acute chest pain are:
1) Identify life-threatening causes;
2) Determine clinical stability; and
3) Assess need for hospitalization versus safety of outpatient evaluation and management.
These concerns entail consideration of the full extent of clinical data. The American College of Cardiology (ACC)/American Heart Association (AHA), ST-Elevation Myocardial Infarction (STEMI) and Non ST Elevation (NSTE)-ACS guidelines categorize chest pain cause into 4 types: STEMI, NSTE-ACS, stable angina, and noncardiac.
The 12-lead ECG, which should be acquired and interpreted within 10 minutes of arrival to a medical facility, is pivotal in the evaluation because of its capacity to identify and triage patients with STEMI to urgent coronary reperfusion. Other ST-ventricular repolarization (T) abnormalities consistent with possible ischemia also mandate prompt evaluation in a hospital setting. In both cases, transfer should be by Emergency Medical Services (EMS); personal automobile for this purpose is associated with increased risk and should be avoided. Three out of five patients with stable angina or noncardiac chest pain that is not life-threatening should be managed as outpatients".

The health plan's determination of medical necessity is upheld in whole.