Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest Pain
 
Treatment:  Inpatient Admission

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

This is a female patient with a medical history of diabetes mellitus, hypertension, congestive heart failure, dyslipidemia, and status post cholecystectomy for cholecystitis.  She presented to the emergency Room (ER) with complaints of chest pain that radiated down her left arm; she reported it to be 7-8/10 in severity.  Her presenting blood pressure was 184/111.  She was consulted by Cardiology.  An electrocardiogram (EKG) was done that showed a normal sinus rhythm; no changes noted from her prior EKG.  Aspirin, oral Labetalol, and one nitroglycerine tablet were administered without relief.  A chest x-ray was performed that revealed clear lungs.  She was monitored on telemetry.  Three sets were drawn with negative results.  A carotid Doppler was performed with normal results.  The patient reported having epigastric pain that worsened after eating.  She was educated on the importance of sitting up after eating to avoid dyspepsia. Psychiatry consulted on the patient for her reported anxiety; Vistaril was ordered and administered as needed. The patient was medically stabilized and discharged home with outpatient follow up instructions.

High-sensitivity cardiac troponin T (hs-cTnT) have 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 2014 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).  All patients who sought medical attention for chest pain and had at least 1 hs-cTnT analyzed during 2 years at the Karolinska University Hospital, Stockholm, Sweden, were included.  They calculated the negative predictive values of an undetectable hs-cTnT and ECG without ischemia for MI and death within 30 days.  The negative predictive value for MI within 30 days in patients with undetectable hs-cTnT and no ischemic ECG changes was 99.8% (95% confidence interval [CI]: 99.7 to 99.9).  The negative predictive value for death was 100% (95% CI: 99.9 to 100).  They conclude that all patients with chest pain, who have an initial hs-cTnT level of <5 ng/l and no signs of ischemia on an ECG, have a minimal risk of MI or death within 30 days, and can be safely discharged directly from the ED.

Many patients admitted to the hospital with cardiorespiratory and other acute syndromes are placed on electrocardiographic monitoring.  Such electrocardiographic surveillance theoretically allows the clinical staff to monitor admitted patients for the development of dysrhythmia, both brady- and tachydysrhythmia-in essence, identify patient decompensation and/or clinical deterioration as it occurs rather than after the event.  Electrocardiographic monitoring, also known as telemetry monitoring or cardiac monitoring, focuses on the detection of clinically significant dysrhythmia, rather than the diagnosis of acute coronary syndrome (ACS) or acute pulmonary edema.  Although electrocardiographic monitoring (ECGM) has advantages and is undoubtedly invaluable in certain patients, significant overuse of cardiac telemetry monitoring does occur.  The impact of this inappropriate use increases the cost of healthcare and can delay the admission process, an unpleasant burden which the hospital and its patients must bear.  In addition, the liberal use of monitoring in unnecessary situations may give the hospital staff a false sense of security and/or desensitize them to alarms.  In many instances, electrocardiographic monitoring may not be necessary (5).

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

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