Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe GERD 
Treatment: Inpatient hospital admission 

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

This patient is a female who presented to the ED with a complaint of chest pain. She reported several days of intermittent substernal chest pain, not radiating and not associated with shortness of breath. She reported that the pain lasted a few seconds and improved with sitting up and when she took a deep breath. She reported having a URI several days prior to this admission, which she treated. She claimed that this pain did not feel like her typical GERD. She denied dyspnea. She has a past medical history of hypertension and GERD. She takes amlodipine for her hypertension. She claims that her cholesterol is well-controlled. There is a past surgical history of lipomyoma which was resected years prior. She was also given Naprosyn for possible pericarditis since she had chest pain that improved when she sat forward. 

Chest x-ray showed mild aortic coiling, normal cardio mediastinal size and a chain of fine sutures in her right lung. There were no acute infiltrates, congestion, mass, pleural effusion or pneumothorax. There were no significant osseous abnormalities. A note written stated that the patient has non-specific T-wave changes on her EKG and normal LV with normal wall motion on her echocardiogram. She has severe GERD and the plan was to start a proton pump inhibitor (PPI) and continue treating her hypertension with amlodipine. A discharge note states that the patient is alert and oriented x3. Discharge instructions were given to her daughter and arrangements were made for outpatient follow-up. 

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 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. 

This patient presented to the ED with a history of chest pain that lasted a few seconds and improved when she sat up and when she took a deep breath. Her troponin was normal and her EKG showed no ST segment abnormalities. The literature recognizes the use of an observation unit for this type of patient. 

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 hospital admission is not substantiated. The insurer's denial is upheld.