Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain. 
Treatment:  Inpatient admission.

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

This is a male patient, who presented to the hospital complaining of chest pain.  His past medical history includes hypertension, hyperlipidemia and coronary artery disease (CAD).  He had a triple coronary artery bypass in the past.  He denied shortness of breath.  The patient reported that he recently discontinued cigarette smoking. 

The patient complained of occasional lightheadedness, but there was no history of syncope.  The patient's electrocardiogram (EKG) showed sinus bradycardia at 58 beats per minute with inverted T waves.  These findings were nonspecific repolarization changes.  There were no ST segment elevations consistent with myocardial injury.  The patient's laboratory results included white blood cell (WBC) count 6.07, hematocrit 32.9, sodium 141, potassium 3.6, glucose 143, blood urea nitrogen (BUN) 24 and creatinine 1.28.  The patient's second creatinine determination was 1.85.  The patient's troponin levels, which trended twice within 6 hours of each other, were both within normal limits.  The patient's pro-B-type natriuretic peptide (BNP) was within normal limits.  The patient's chest X-ray showed a sternotomy scar and a slight linear scar or atelectasis of the right middle lung field.  The patient's physical exam did not describe any abnormalities.  The patient's assessment included chest pain with negative troponin and electrocardiogram (EKG) with no ST segment abnormalities.  The patient's assessment also included acute kidney injury, hypertension, hyperlipidemia, coronary artery disease (CAD), and anemia.  He was admitted to telemetry and was scheduled for a stress test by cardiology.  The patient decided to leave against medical advice (AMA) despite being explained the risks of leaving.  It was recommended that the patient follow-up with his primary doctor as soon as possible, and return to the Emergency Department (ED) immediately, if he had more chest pain or other cardiac symptoms.

High-sensitivity cardiac troponin T (hs-cTnT) has been introduced as a highly sensitive and early biomarker of myocardial damage.  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).  A study from Sweden evaluated the significance of undetectable troponin levels and electrocardiograms (EKGs) which did not show signs of ischemia in patients presenting to the ED with chest pain.  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 conclude that all patients with chest pain, who have an initial hs-cTnT level of less than 5 and no signs of ischemia on an EKG, have a minimal risk of MI or death within 30 days, and can be safely discharged directly from the ED.

Multiple observation protocols have been developed, which have been shown to be safe and deliver effective care.  Recognizing the value of an Observation Unit, studies report that over one third of hospitals now have implemented an ED observation unit.

In this case, this patient presented to the ED with a complaint of chest pain and occasional lightheadedness.  The patient's troponin level trended twice within 6 hours apart, were negative, and his EKG showed no ST segment elevations or depressions.  His chest X-ray showed no significant changes.  The literature recognizes the use of an observation unit for this type of patient. 

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

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