Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

This is an adult patient that presented to the hospital complaining of sudden onset of chest pain, shortness of breath and lightheadedness. Past medical history was significant for hypertension, diabetes mellitus, and myocardial infarction. Upon arrival to the hospital, vital signs were stable [BP (blood pressure) 182/93, pulse 80]. Physical examination revealed no significant abnormality. A 12-lead electrocardiogram (ECG) revealed normal sinus rhythm with inverted T waves (interval on an ECG) in the lateral leads. Serum blood testing demonstrated no elevation in troponin (< (less than) 0.01). A Computer Tomography scan of the chest was performed, and no pulmonary embolism or aortic dissection were noted. An exophytic mass of the liver was found incidentally. The patient was admitted to the hospital for observation and treatment. Cardiac catheterization demonstrated no significant obstruction and a patent stent in the left anterior descending artery and echocardiogram demonstrated a preserved left ventricular ejection fraction of 55%(percent). The patient underwent additional gastroenterology workup for the liver mass and was ultimately discharged home with plans for an outpatient liver Magnetic Resonance Imaging study. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. This patient's pretest probability of coronary artery disease is intermediate. Utilizing the HEART (history, electrocardiography, age, risk factors, troponin) score the patient was considered low risk. Risk assessment of patients presenting with chest pain and no significant ST (interval on an ECG) changes on an electrocardiogram (ECG) was reviewed by Hedayati et al. Using the HEART score risk stratification schema, this patient would have a low to 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. Fernando Bellolio noted that patients presenting with chest pain, that were managed in an observation unit, had similar 30-day myocardial infarction rates as those admitted to the hospital. Admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been managed at a lower level of care.

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 admission is not substantiated.