Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

 

This is a patient with no significant past medical history that presented to the hospital complaining of chest pain at rest radiating to the epigastrium.  He recently quit smoking after 40 years of cigarette use.  Upon arrival to the hospital vital signs were stable (BP 123/83, Pulse 68).  Physical exam was without abnormality.  12 lead electrocardiogram (ECG) demonstrated normal sinus rhythm with an incomplete right bundle branch pattern and no evidence of ischemic ST changes.  Serum blood testing demonstrated no elevation in troponin (< [less than] 0.01). The patient was admitted to the telemetry ward for further work up and treatment. Echocardiogram with Definity contrast demonstrated a preserved left ventricular ejection fraction and normal wall motion.  An exercise perfusion study was performed and demonstrated a left ventricular ejection fraction of 54-57% (percent) with anterior wall reversible defects.  The patient exercised to 89% of maximally predicted heart rate and had a Duke treadmill score of 9.  Of note the report noted that perfusion images were of poor quality: "images are suboptimal due to presence of diaphragmatic attenuation and visceral artifact".  The patient was ultimately discharged home on medical therapy with plans for further outpatient work up.

This patient presented with atypical chest pain. He had no significant ECG abnormalities and no elevation in serial serum troponin studies.  Based on history and presentation alone, this patient had a low short-term risk of death and nonfatal cardiac ischemia.(Reference1)  He  underwent exercise stress testing and had a Duke treadmill score of + [plus] 9.  Evidence of ischemia was noted on myocardial imaging; however, this was discordant with exercise capacity and images were deemed to be of poor quality.  These findings are consistent with a low one-year mortality and a low probability of significant coronary artery disease. (Reference 2) Utilizing the HEART (evaluates cardiac risk factors) score he is considered low risk (2 points). (Reference 3)  Utilizing the Thrombolysis In Myocardial Infarction (TIMI) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1). (Reference 4) 

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 4).  Using the HEART score risk stratification schema, this patient would have a low 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.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. Ultimately this patient underwent myocardial perfusion imaging that revealed no evidence of ischemia- confirming the aforementioned low risk stratification.  In conclusion, inpatient admission was not medically necessary for this patient. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.