Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Atypical Chest Pain

Treatment:  Inpatient Hospital

The insurer denied the Inpatient Hospital.  The denial was upheld. 

This is a middle-aged male, who presented to the Hospital Emergency Room in 2019 via Emergency Medical Services with complaints of shortness of breath and chest pain for 5 minutes.  The patient reported using cocaine prior to the onset of symptoms.  He has a history of coronary artery disease (status post coronary artery bypass graft in 2014), automatic implantable cardioverter defibrillator (AICD) in 2016, 4 previous heart attacks, hypertension, diabetes, bipolar disorder, and chronic obstructive pulmonary disease, and smokes cigarettes for 30 years.  He was given nebulizer treatments by EMS prior to his arrival.  His initial vital signs were stable upon arrival to the emergency department.  The patient had 2 negative troponin levels.  His EKG showed normal sinus rhythm with no ST changes.  He received Solu-Medrol, albuterol and oxygen via nasal cannula.  A chest X-ray revealed no acute findings.  An echocardiogram was done and showed "normal size and cavities of the heart."  The patient was admitted for atypical chest pain.  When he was clinically stable he was discharged home with instructions to follow up with his primary cardiologist. 

Retrospective studies of patients with cocaine-associated chest pain suggest that a strategy of discharging patients from the Emergency Department after a 12-hour observation period, if they do not have evidence of ischemia, should be associated with a very low rate of complications.  Investigators prospectively evaluated the safety of a 9-to-12-hour observation period in patients with cocaine associated chest pain who were at low-to-intermediate risk of cardiovascular events.  Consecutive patients who reported or tested positive for cocaine use and who received protocol-driven care in a chest-pain observation unit were included.  Patients, who had normal levels of troponin I without new ischemic changes on electrocardiography and who had no cardiovascular complications (dysrhythmias, acute myocardial infarction, or recurrent symptoms) during the 9-to-12-hour observation period, were discharged from the unit.  The main outcome was death from cardiovascular causes at 30 days.  Three hundred forty-four patients with cocaine-associated chest pain were evaluated.  Forty-two of these patients (12 percent) were directly admitted to the hospital.  The study cohort comprised the remaining 302 patients.  During the 30-day follow-up period, none of the patients died of a cardiovascular event {0 percent; 95 percent confidence interval, 0 to 0.99), and only 4 of the 256 patients for whom detailed follow-up data were available had a nonfatal myocardial infarction (1.6 percent; 95 percent confidence interval, 0.1 to 3.1).  All four nonfatal myocardial infarctions occurred in patients who continued to use cocaine.  The investigators conclude that patients with cocaine-associated chest pain who do not have evidence of ischemia or cardiovascular complications over a 9-to-12-hour period in a chest-pain observation unit have a very low risk of death or myocardial infarction during the 30 days after discharge (7).

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.