Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Angina

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld 

This patient presented to the hospital complaining of chest discomfort and pounding that radiated to his left arm. The pain occurred at rest and lasted for 45 minutes before it subsided. Past medical history was significant for hypertension.  Upon arrival to the hospital, vital signs were stable: BP (blood pressure) 132/82 mmHg (millimeters of mercury) , Pulse 87 bpm (beats per minute). No abnormal findings were noted on physical examination. 12 lead electrocardiogram (ECG) revealed normal sinus rhythm with T wave (interval on an ECG) inversions.  Serum blood testing was significant for a creatinine of 1.6.  Serum troponin was not elevated x2 (<0.010 mcg (micrograms/L(liter)). Stress echocardiogram was performed and revealed no evidence of ischemia on stress electrocardiogram and no stress induced wall motion abnormalities. However, an inferior wall motion abnormality was noted at baseline.  Cardiac catheterization was performed and revealed no evidence of coronary artery obstruction. The patient was discharged on medical therapy for hypercholesterolemia and hypertension.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. Full hospital admission was not necessary for this patient that presented with chest pain. His pretest probability of coronary artery disease is low. (Reference 1) Utilizing the HEART (patient history, ECG abnormalities, age, risk factors, troponin) score he was considered intermediate risk (4 points). (Reference 2) Risk assessment of patients presenting with chest pain and no significant ST (interval on a ECG) changes on ECG was reviewed by Hedayati. (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 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 health plan acted reasonably with sound medical judgment in the best interest of the patient.

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