Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain, COVID-19. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is overturned. 

This is a male patient who presented to the Emergency Department (ED) with an episode of chest pressure and shortness of breath that lasted approximately 2 minutes earlier in the evening. The patient also had left upper extremity numbness. All of the patient's symptoms resolved when he got to the hospital. The patient stated that he had a similar episode in the past and also went to the ED. The patient denied any other symptoms. The patient has a past medical history of hyperlipidemia. In the ED, the patient was found to be COVID-19 positive. When the patient was found to be COVID-19 positive, the patient was moved to a private room for isolation. A note states that given this patient's COVID-19 positive status, he should be a full admission to telemetry. 

High-sensitivity cardiac troponin T (hs-cTnT) has 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). A 2014 study from Sweden evaluated the significance of undetectable troponin levels and electrocardiograms (EKGs) which did not show signs of ischemia in patients presenting to the ED with chest pain. All patients who sought medical attention for chest pain and had at least 1 hs-cTnT analyzed during 2 years at the Karolinska University Hospital, Stockholm, Sweden, were included. They calculated the negative predictive values of an undetectable hs-cTnT and EKG without ischemia for MI and death within 30 days. The negative predictive value for MI within 30 days in patients with undetectable hs-cTnT and no ischemic EKG changes was 99.8% (95% confidence interval [CI]: 99.7 to 99.9). The negative predictive value for death was 100% (95% CI: 99.9 to 100). They conclude that all patients with chest pain who have an initial hs-cTnT level of less than 5 ng/l (nanograms per liter) and no signs of ischemia on an EKG have a minimal risk of MI or death within 30 days, and can be safely discharged directly from the ED.

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. In this case, this patient presented to the ED with a complaint of a brief episode of chest pain and transient numbness in his left arm. The patient's troponins were negative and his EKG and chest X-ray were within normal limits. The literature supports that inpatient hospital admission was not medically necessary for this patient, and he could have been safely placed on observation status. However, this reviewer thinks that this patient is an exception because of his positive COVID-19 infection status and the hospital's direction that he be placed in a private room for isolation purposes. This reviewer does not think that admission to a private room for isolation purposes is consistent with observation status and does think that the inpatient hospital admission was medically necessary because of the patient's COVID-19 positive status. Given this patient's positive COVID-19 status, inpatient admission was medically necessary for this patient. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the inpatient hospital admission should be overturned. The medical necessity is substantiated.