Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a female who presented with chest pain that was present since 4 AM on the day of admission. She described it as a sticking pain. She received nitroglycerin x2 and aspirin on route to the hospital. The pain was located in the anterior chest and was mild to moderate intensity. It was sudden in onset and there was no history of shortness of breath or diaphoresis. There were no aggravating or alleviating factors described. Her review of systems was negative except what has been described above. On physical exam she was described as being in no distress and no physical abnormalities were described on her examination. The patient has a past history of CAD with myocardial infarction (MI) and stent placement, and PCI for restenosis of the LAD. She has severe systolic dysfunction with an ejection fraction of 19% noted several years ago. She has a history of deep vein thrombosis (DVT) since several years ago and at that time presented to the ED because of chest pain. She was last admitted to this hospital because of chest pain in early 2019.

The risk of acute myocardial infarction is increased by a factor of 24 during the 60 minutes after the use of cocaine in persons who are otherwise at relatively low risk. The serum half-life of cocaine is 45 to 90 minutes; only 1 percent of the parent drug can be recovered in the urine after it is ingested. Thus, cocaine can be detected in blood or urine for only several hours after its use. (1) 

Current guidelines recommend measurement of a cardiac injury marker which should include a highly sensitive and specific cardiac troponin measurement. Current troponin assays have improved sensitivity, specificity and precision at lower levels. Current studies indicate that occurrence of myocardial infarction can be identified within 3 hours of emergency department arrival.(2, 3)  It has been demonstrated among patient's presenting to the emergency department with chest pain, that those with a less than 5% probability of myocardial infarction can be identified from the presenting symptoms, past history, and electrocardiogram. 

A 2014 study hypothesized 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. The main group of patients studied was those with a first hs-cTnT level of <5 ng/l (undetectable) measured in the ED, combined with no ST-segment changes, indicating myocardial ischemia on the ECG. In a large cohort of 14,636 consecutive patients who sought medical attention for chest pain in the ED, they found that a first hs-cTnT level of <5 ng/l combined with no signs of ischemia on the ECG had a 99.8% negative predictive value for MI and a 100% negative predictive value for death within 30 days.(4)    

This patient presented to the ED with chest pain which was atypical for ACS in that it was described as sharp. She admitted to using cocaine and stated that her last use occurred the day prior to this admission. Her workup included troponin x3 which were within normal limits, EKG x4, which were abnormal but showed no acute changes and a chest x-ray. According to the literature cited this patient was beyond the period of time when cocaine -induced myocardial infarction occurs. In addition, she had a workup which could have been done in an observation unit rather than hospital admission. 

Inpatient admission was not medically necessary. 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.