Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain 

Treatment: Inpatient admissions

The insurer is denied coverage for inpatient admissions.

The denial is upheld. 

The patient was then a female with an immunocompromised status and ovarian cancer who presented to the Emergency Department (ED) with complaints of chest pain and fever. The patient reported not been feeling well for the past several days and saw her primary care provider prior to coming to the ED.  The patient reported experiencing substernal chest tightness that radiated to the right chest and shortness of breath. The patient also reported chronic cough, fever, chills and myalgia. The patient smoked cigarettes daily, and also used cocaine. Further history from the patient indicated that the patient had chest pain for then the past month which had gotten worse several days prior to presentation. A note written in the morning stated that the patient was clinically doing well, not in heart failure, not in any pain and had a good appetite. The patient was hemodynamically stable and afebrile. The note stated that the patient was stable for discharge home. The patient was recommended to take aspirin 81 mg daily and follow-up with her primary medical doctor.

The onset and duration of cocaine's effects depend on its route of use, consequently varying its cardiovascular and hemodynamic effects. In general, the intravenous and inhaled routes have a very rapid onset of action (seconds) and short-lived (30 min) duration compared with drug that is mucosally absorbed. The excretion of cocaine and its metabolites is not affected by cocaine's route of ingestion; the half-life of cocaine is usually 60 to 120 min and that of its metabolites is approximately 4 to 7 hrs. Cocaine's hemodynamic effect is dose-dependent; early stages of toxicity induce heart rate and blood pressure (BP) elevation (10% to 25% of baseline); advanced stages show further elevations in heart rate and BP. In late stages, a significant depressive effect is found, with severe bradycardia and circulatory failure. 

Observation units have been developed to improve care of patients who do not have an obvious clinical condition after their ED evaluation. Selected people with chest pain are one of the most prominent groups of such patients. They benefit from observation unit care with standardizing timely and accurate risk assessment, implementation of clinical decision rules, and use of accelerated diagnostic protocols. They are a modern structure for cost-effective, high-quality outpatient/in-hospital patient care. (4)

In this case, this patient presented to the Emergency Department (ED) with a complaint of chest pain and fever. The patient also reported shortness of breath, cough, chills and myalgia. The patient had an active history of cocaine use, with the last use on the day prior to the ED arrival. Although this patient is known to have used cocaine, there was no direct correlation between her use of cocaine and the onset of her pain. The patient's troponin levels were within normal limits (negative), and would have been expected to be positive if myocardial injury was present. The patient did not have any changes suggesting acute myocardial injury or ischemia on her electrocardiogram (EKG). The workup and monitoring that this patient required could have been done in a less acute care setting, such as an observation unit, and did not require inpatient level of care. Thus, inpatient admission was not medically necessary to treat this patient's medical condition.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial should be upheld.