Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.

Treatment inpatient stay.

The insurer denied coverage for inpatient stay.

The denial is upheld.

This patient that presented to the hospital complaining of chest pain and tachycardia with heart rates up to 180.  Past medical history was significant for ischemic heart disease, transient ischemic attack (TIA), atrial fibrillation treated with catheter ablation, and esophageal carcinoma status post esophagectomy.  Upon presentation to the ED (emergency department) heart rate was 67 and blood pressure (BP) was148/67. Physical examination was unremarkable.  12 lead electrocardiogram (ECG) revealed normal sinus rhythm with inverted T (interval on ECG) waves in the inferior leads and a QT (interval on ECG) interval of 483 on dofetilide therapy. Serum blood testing revealed no evidence of troponin rise (<0.03 ng/ml [nanogram per milliliter]) and elevated glucose (179).  Chest pain was persistent and severe, and the patient was brought for cardiac catheterization that revealed diffuse non obstructive disease and a chronic total occlusion of the left circumflex artery.  Echocardiogram revealed preserved left ventricular ejection fraction (LVEF).  The patient was ultimately treated with medical therapy and discharged with follow up. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Full hospital admission was not medically necessary for this patient that presented with chest pain.  His pretest probability of coronary artery disease is high. (Reference 1) Utilizing the HEART [History, ECG, Age, Risk factors, and Troponin] score he was considered intermediate risk (5 points). (Reference 2) Risk assessment of patients presenting with chest pain and no significant ST (interval on ECG) changes on ECG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have an 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. (References 4,5) They found no significant difference in outcome at 30 days between the two groups.  Fernando Bellolio et al. 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. (Reference 5) 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.

The insurer's denial of coverage for the inpatient stay is upheld. Medical Necessity is not substantiated.