Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

Asked to review the case of a gentleman that presented to the hospital with complaints of chest pain and lightheadedness.  Chest pain occurred after eating and was described as dull and constant, non-radiating.  He presented to an urgent care center and was noted to have sinus bradycardia with a heart rate of 41 and first degree atrioventricular (AV) block (PR interval prolongation). He was sent to the emergency department.  Past medical history was significant for hypertension and asymptomatic bradycardia.  Upon arrival, vital signs were stable (Pulse 50 bpm, BP 123/76 mmHg).  Physical examination revealed no abnormal findings. 12 lead electrocardiogram demonstrated sinus bradycardia with a prolonged PR interval and no ST (segment) or T wave abnormalities.  Serum blood testing demonstrated a normal troponin (<0.003).  The patient was admitted to the hospital for additional testing and treatment.  Perfusion testing revealed a small area of reversible ischemia in the inferior apex with preserved left ventricular function (LVEF 73%).  Computed tomography (CT) angiogram demonstrated a coronary calcium of zero consistent with no evidence of coronary artery disease.  The patient was ultimately discharged home. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with atypical chest pain, lightheadedness, sinus bradycardia and a past medical history of hypertension. His pretest probability of coronary artery disease was low.(Reference 1)  Utilizing the History, Electrocardiogram (EKG), Age, Risk Factors, and Troponin (HEART) score he was considered low risk.(Reference 2)  Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days .  (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low 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.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. Ischemia work up could have been performed in an outpatient setting, especially in light of a largely normal perfusion study. 

With regard to the patient's symptoms of lightheadedness, this patient falls into a low to intermediate risk group for syncope.  According to joint guidelines such patients should be managed utilizing a structured emergency room (ER) observational protocol (Reference 4) In a study of individuals presenting to the emergency room, patients that were low risk or intermediate risk for cardiac events had an excellent prognosis and did not require full hospital admission to the hospital for further testing. (Reference 5).  In conclusion, inpatient admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower level of care. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.