Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain; Abdominal Pain.

Treatment: Inpatient hospitalization.

The insurer denied inpatient hospitalization.

The denial was upheld.   

This female patient came to the hospital with complaints of aching pain and cramping in her abdomen which radiated to her left chest. The patient has a past medical history of coronary artery disease (CAD) with placement of a stent. She also has congestive heart failure (CHF), hypertension, diabetes mellitus, hyperlipidemia, chronic gastritis and anxiety disorder. The patient claims that this pain is similar to other times when she had gastritis and she currently has not been taking any medications for this. She denied nausea or vomiting and denies chest pain, palpitations and other complaints. On physical exam there was tenderness to palpation of the epigastric region. There was no rebound, no guarding and no suprapubic tenderness. No other abnormalities were noted. Her electrocardiogram (EKG) showed normal sinus rhythm. Her glucose was elevated and there was concern for diabetic ketoacidosis (DKA) with abdominal pain. Because of back pain in the setting of abdominal pain there was concern for aortic dissection. A computed tomography angiogram (CTA) of the chest, abdomen and pelvis was done showed the thoracic and abdominal aorta are normal size and contour without evidence of dissection, no evidence of pulmonary embolism. Her troponin was within normal limits. Portable chest x-ray showed no evidence of pneumothorax and the impression was no acute cardiopulmonary disease. Records indicate she has been medically optimized and she was discharged to follow up with her primary doctor and cardiologist.

High-sensitivity cardiac troponin T (hs-cTnT) has been introduced as a highly sensitive and early biomarker of myocardial damage. (1) 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). (2, 3) A study from Sweden evaluated the significance of undetectable troponin levels and EKGs which did not show signs of ischemia in patients presenting to the emergency department with chest pain. (4) According to these studies, all patients with chest pain who have an initial hs-cTnT level of <5 ng/l (nanogram per liter) and no signs of ischemia on an ECG have a minimal risk of MI or death within 30 days and can be safely discharged from the ED. 

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. (5)

Emergency Department Observation Units (Obs Units) provide a setting and a mechanism for further care of Emergency Department (ED) patients. A 2018 study described a protocol-driven, type 1, complex 20 bed Obs Unit with 36 different protocols. They wanted to understand how the different protocols performed and what types of care were provided. These authors conclude that an Obs Unit can care for a wide variety of patients who require multiple consultations, procedures, and care coordination while maintaining an acceptable length of stay and admission rate. (7)

The literature cited shows that this patient would have been an appropriate candidate for an observation unit since she had no troponin elevations and no changes of injury on her EKGs that were consistent with acute myocardial injury or ischemia. This patient was an ideal candidate for an observation unit.

The health plan acted reasonably with sound medical judgment 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 is upheld.