Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Chest Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.  The denial is upheld.

This patient is a female who presented to the Emergency Department (ED) with a complaint of chest pain for two weeks in addition to worsening dizziness.  The patient reports that the chest pain started initially while she was doing laundry three weeks ago.  It was intermittent, burning and radiated to the epigastric region and back, worsened with cough.  For the past two days she started having dizziness with motion and feeling of the room spinning; however it has improved since she has been in the hospital.  She had a systolic blood pressure of 190 at home yesterday, which was associated with headache and now has also improved.  According to the patient's primary medical doctor (PMD) she had an electrocardiogram (EKG) done which showed left bundle branch block.  She was recently referred to a cardiologist, but has not yet had the appointment.  She has a past medical history of hypertension, hyperlipidemia and coronary artery disease (CAD).  She was told that she had two vessel disease two years ago.  With the exception of complaints listed in the History of Present Illness (HPI), the review of systems is negative except for right posterior rib pain which is been present for the past year.  The vital signs recorded  include temperature 36.3 C., heart rate 74, oxygen saturation 96% on room air, respirations 16 and blood pressure 142/89.  The record indicates that she was having no pain at the time of physical examination.

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 EKGs which did not show signs of ischemia in patients presenting to the emergency department with chest pain.  (4) All patients who sought medical attention for chest pain and had at least 1 hs-cTnT analyzed during 2 years at the Karolinska University Hospital, Stockholm, Sweden, were included.  The negative predictive value for death was 100% (95% CI: 99.9 to 100).  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 . 

This patient presented to the ED with a history of chest pain that had been present for two weeks.  Certainly, it would have been expected that her troponin levels would have been elevated if she did have myocardial injury over that period of time.  The Troponin x 3 was within normal limits and her EKG showed left branch block, but there were no primary EKG abnormalities consistent with acute myocardial injury that were seen.  This patient would have been an appropriate candidate for an Observation unit since she had no troponin elevations and no changes to indicate injury on her EKG's that were consistent with acute myocardial injury or ischemia.  The literature that this reviewer has cited makes it clear that acute hospital admission for this type patient is not medically necessary and that this patient was an ideal candidate for an observation unit. 

The health plan did act reasonably with sound medical judgment and in the best interest of the patient. 

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.