Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain.
Treatment: Inpatient admission.

The insurer denied coverage for an inpatient admission.  The denial is upheld.

The patient with a history of hypertension, chronic obstructive pulmonary disease (COPD), pulmonary embolism, hyperthyroidism and active cocaine use, presented to the hospital complaining of shortness of breath and chest pain radiating to the left arm. He reported using cocaine the night prior to admission.  Upon arrival to the emergency department, the patient reported that his chest pain had resolved. Vital signs were stable: BP (blood pressure) 142/85 and pulse 105 bpm (beats per minute). Physical examination revealed bilateral wheezing and oxygen saturation was 94% on Room Air. A 12-lead electrocardiogram revealed normal sinus rhythm without ST (interval on an ECG (electrocardiogram) or T (interval on an ECG) wave abnormalities. Serum blood testing revealed an elevated high sensitivity troponin level of 10.9 ng (nanograms)/L (liter) and B (brain) type natriuretic peptide was 25 pg (picograms)/ml (milliliters). Urine toxicology testing was positive for cocaine. A Computerized tomography (CT) of the chest revealed no evidence of pulmonary embolism or pneumonia and no evidence of aortic dissection. An echocardiogram revealed a preserved left ventricular ejection fraction without wall motion abnormalities. The patient was treated with intravenous steroids and nebulizer therapy for a mild COPD exacerbation and discharged with follow up.   

The patient presented with intermittent chest pain in the setting of active cocaine use. His pretest probability of coronary artery disease is low. (Reference 1) Utilizing the HEART (History, ECG, Age, Risk factors, and Troponin) score, he was considered low risk. (Reference 2) Utilizing the TIMI (Thrombolysis in Myocardial Infarction) risk score, he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1). (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST changes on an ECG 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.  

Investigators studying more than 300,000 hospital admissions for chest pain in the setting of cocaine, found that patients presenting with chest pain following cocaine and no other significant risk factors had a low risk of major adverse cardiac events and mortality. They concluded that most patients did not require hospital admission. (4)

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 inpatient hospital services is not substantiated.