Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Traumatic rib fracture
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

This is a male patient with a past history of irritable bowel syndrome, diverticulosis, chronic back pain, hypertension, prediabetes, and depression. The patient's past surgical history includes ventral hernia repair and appendectomy. The patient presented to the hospital with complaints of rib pain secondary to a traumatic fall that occurred the night prior. The patient complained of chest pain which was rated as 10/10 in severity, over the left lower chest and left upper abdomen. The patient reported that his chest pain worsened with movement, inspiration and/or coughing. The patient denied injury in any other part of his body. The patient's initial troponin level was 0.04. The patient's repeat troponin on the same day was 0.02. The patient's rib x-rays showed fracture of the left 7th-10th ribs with no evidence of pneumothorax or hemothorax. The working diagnosis was traumatic rib fracture and chest pain, to rule out acute coronary syndrome (ACS). The plan was to admit the patient to the Telemetry unit to rule out ACS, to track his troponins and electrocardiogram (EKG). The patient was discharged once medically stable. 
It has been suggested that there is a diagnostic difference between the troponin levels that rises after admission versus a troponin level that falls after admission. Biener and his colleagues found that the continuing rise of the troponin level was more likely due to coronary disease and frequently supported a diagnosis of non-ST segment elevation myocardial infarction (NSTEMI). On the other hand, a falling troponin level was more often associated with a non-acute coronary syndrome condition. They did make it clear that the final diagnosis always had to be made with consideration of a clinical context of the biomarker testing (Biener et al., 2013). 

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 Emergency Department (ED) observation unit (Wiler et al., 2011). In this case, this patient came to the hospital because of pain that resulted from a mechanical fall that he had the previous day. The patient reported severe pain in the left-side of his chest which was the result of fractured ribs documented on his chest x-ray. Past history of coronary artery disease (CAD) is mentioned but there was no clinical documentation to support this history. As per literature review, the patient's slight elevation in troponin on admission that quickly returned to normal did not support a diagnosis of myocardial damage. The patient's EKG did not show any evidence of ST segment elevation. This patient simply had chest pain from a mechanical fall which produced several fractured ribs. Based on the review of the medical literature, this patient's care could have been provided at a lower level of care, such as an observational unit. 

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

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