Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain 

Treatment: the inpatient admission

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

This patient is a morbidly obese female, who is a current every day smoker and a current drug abuser who is on methadone. She has a past medical history which includes hypertension diabetes mellitus, which is diet controlled, gastroesophageal reflux disease (GERD), acute cholecystitis and laparoscopic cholecystectomy done. She also has chronic back pain due to a herniated disc and history of multiple chronic urinary tract infections (UTI). She has known coronary artery disease (CAD) and her last coronary angiogram. At that time, she had a percutaneous coronary intervention (PCI) of a proximal left anterior descending (LAD) which was 70% occluded and was 0% occluded after the PCI was done. Her left circumflex (LCx) was patent as was the left main (LM) and right coronary artery (RCA). Her left ventricular end-diastolic pressure (LVEDP) was 17 and her left ventricular ejection fraction (LVEF) was 50-55%. The patient presented to the Emergency Department (ED) today with a complaint of worsening left-sided chest pain that started around 4 AM and woke her from sleep. A nurse's note states that the patient reports no change in chest pain after one sublingual (SL) nitroglycerin (NTG). She refuses additional dose and chest pain remains 7/10. She was admitted to a telemetry unit for monitoring. An echocardiogram was done and revealed mild concentric left ventricular hypertrophy (LVH) with normal left ventricle (LV) wall motion. The patient was originally scheduled for discharge on a specified date, but stayed overnight due to need for methadone maintenance administration in the morning. She was given her methadone maintenance dose the following morning and discharged home, with arrangements made for outpatient follow-up.

High-sensitivity cardiac troponin T (hs-cTnT) have 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 EKG's which did not show signs of ischemia in patients presenting to the Emergency Department with chest pain. They calculated the negative predictive values of an undetectable hs-cTnT and ECG without ischemia for MI and death within 30 days. 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. 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. (7)

This patient, with known coronary artery disease (CAD) and previous percutaneous coronary intervention (PCI), presented to the hospital with a complaint of chest pain. Her workup showed that troponin series were normal and her EKG showed no signs of ST segment change or T-wave change consistent with acute myocardial injury or ischemia. The literature recognizes the use of an Observation unit for this type of patient.  However, a monitored level of care or telemetry unit is not the same thing and the literature that this reviewer has cited shows that a monitored level of care was not medically necessary.  

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 is upheld. The medical necessity is not substantiated.