Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Myocardial Infarction

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission.  The denial is upheld.

This case involves an adult patient that presented to the hospital with severe chest pain. The workup revealed an electrocardiogram (ECG) without significant abnormality, and an echocardiogram that demonstrated a preserved left ventricular ejection fraction without wall motion abnormalities. Serum blood testing demonstrated an elevation in troponin (24) consistent with non-ST (interval on an ECG) elevation myocardial infarction (NSTEMI). The patient was transferred for further care. The patient underwent cardiac catheterization that revealed no significant coronary artery obstruction. The patient was ultimately diagnosed with NSTEMI due to vasospasm or transient thrombosis and discharged home on medical therapy.

Full hospital admission was not medically necessary for this patient that presented with chest pain and a positive serum troponin. This patient was transferred for cardiac catheterization after presenting to an outside hospital following NSTEMI. Utilizing the HEART (history, ECG anomalies, the patient's age, any risk factors present, and elevated Troponin) score, the patient was considered intermediate risk. Risk assessment of patients presenting with chest pain and no significant ST changes on an ECG was reviewed by Hedayati et al. 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 measurement, echocardiography and ischemia work up prior to discharge. However, numerous studies have demonstrated that work up 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. They found no significant difference in outcome at 30 days between the two groups. Fernanda Bellolio noted that patients presenting with chest pain, which were managed in an observation unit, had similar 30-day myocardial infarction rates as those admitted to the hospital. This patient was evaluated and treated in an outside hospital prior to presenting for cardiac catheterization. The patient underwent an uncomplicated procedure, and no significant coronary abnormalities were identified. Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care. In conclusion, full hospital admission was not medically necessary.

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 a full hospital admission is not substantiated.