Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld. 

This is a woman with a past medical history that includes hypertension, hypothyroidism, right nephrectomies due to congenital kidney disease, and chronic back pain.

She presented to the emergency department (ED) complaining of chest pain that had begun that day, 9/10 (on a pain scale of 1-10) in intensity, with similar pain in the past, typically lasting a few hours; often worse lying down and occasionally after meals. There was no associated shortness of breath, nausea, fever, or chills. The pain radiated to her back. There was no history of premature coronary disease in any first degree relative. A stress echocardiogram three months earlier by her cardiologist was negative (normal). She noted poorly controlled hypertension on one agent (lisinopril). The patient noted an unexplained 10-pound weight gain over the recent months.

Vital signs were unremarkable other than occasional small elevations in blood pressure. Physical exam was reassuring. Labs were reassuring. Radiographic evaluations, including chest x-ray and computed tomography (CT) Angiogram of the chest, were largely unremarkable other than for incidental findings (lung nodules, granulomas, calcification of psoas muscle). EKG (echocardiogram) was unremarkable other than non-specific T-wave (interval on an EKG) abnormalities; there was no prior EKG submitted for comparison.

Her HEART (history, EKG, age, risk factors, and troponin) Score was 3, hypertension, and an indeterminate EKG. This puts her at low risk, indicating that an expedited workup without need for admission is appropriate. This score has been validated multiple times, including analyses comparing it favorably to other methods of risk evaluation. 

Two troponins were adequate to exclude myocardial infarction and to confirm her low risk of adverse events in the setting of atypical chest pain. The atypical nature of the patient's pain was documented multiple times. The recent stress test for this same pain should have also increased suspicion that this presentation was not consistent with cardiac pain, as a normal stress echo is correlated with a less than 1% cardiac event rate within the following year. Additionally, the diagnosis identified in the hospital's appeal as the reason warranting inpatient admission was Unstable Angina. No treatment was given in the ED nor during her hospitalization for unstable angina (a form of acute coronary syndrome, which would require aggressive medical therapy and is considered a medical emergency), nor was that diagnosis ever formally made; rather, she was admitted with chest pain which was described by multiple providers as atypical. Finally, the MCG (Milliman Care Guidelines) criteria submitted specifically referenced the fact of "new onset symptoms" as supportive evidence of the diagnosis of unstable angina, and of the need for inpatient admission, yet the medical record indicates in multiple locations that these symptoms had been ongoing for many months, at various times.

The inpatient hospital admission was not medically necessary for the patient. The reasons for this conclusion are outlined in the prior response; her low-risk presentation of atypical chest pain was effectively and appropriately evaluated in the emergency department, after which only outpatient follow-up was warranted. This could have included an outpatient cardiac catheterization if that was considered necessary. This is consistent with the documentation submitted for review.

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

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