Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Hospital Admission
The insurer denied coverage for full hospital admission
The denial is upheld

The patient is a male with a history of hypertension and diabetes who presented to the Emergency Department (ED) complaining of chest pain for several hours prior to arrival. The patient reported large fluctuations in blood pressure when measured at home. The patient's physical examination upon arrival was benign and no abnormalities were reported.  The patient's blood pressure (BP) was 134/96.  The patient's vital signs remained stable throughout the patient's hospitalization. The patient's electrocardiogram (EKG) revealed no evidence of ischemic changes, and the patient's serial troponin-I studies were negative (less than 0.2ng/ml). The patient's transaminase levels were noted to be elevated, and the patient's statin therapy was discontinued. The patient reported that he underwent cardiac catheterization (diagnostic) in a few years ago at an outside hospital and no abnormal findings were noted. The patient was treated with intravenous (IV) hydration and was discharged with outpatient follow up. 

Based on the review of the medical record and literature, full hospital admission was not necessary for this patient who presented with chest pain.  As per Fihn et al. (2012), the patient's pretest probability of coronary artery disease is intermediate.  Utilizing the History, Electrocardiogram, Age, Risk factors, and Troponin (HEART) score he was considered intermediate risk, with a score of 5 points (Poldevaart et al., 2017). Risk assessment of patients presenting with chest pain and no significant ST changes on electrocardiogram (EKG) was reviewed by Hedayati et al. (2018).  Using the HEART score risk stratification schema, this patient would have an intermediate 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. These findings are concerning and warrant management and evaluation that includes serial troponin monitoring, echocardiography and ischemia work up prior to discharge. However, numerous studies have demonstrated that workup can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care (Wright et al., 2016; Fernanda et al., 2017). They found no significant difference in outcome at 30 days between the two groups.  

Based on the review of the medical record and literature, full hospital admission to treat an acute cardiac event was not medically necessary for this patient. This patient could have been managed at a lower level of care. 

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

The insurer's denial of coverage for the full hospital admission should be upheld. The medical necessity is not substantiated.