Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 
Treatment: Inpatient hospital admission.

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

This is a female patient who presented to the Emergency Department (ED) after having substernal chest pain and shortness of breath. There was some improvement in the shortness of breath when she took albuterol. Her past medical history was significant for asthma, obesity, gastroesophageal reflux disease (GERD), and recent pulmonary embolus for which she was now on Eliquis and inferior vena cava (IVC) filter.  In the ED, the patient's oxygen saturation was 97%, and her respiration rate was 26. The patient's electrocardiogram (EKG) was unremarkable and her troponin was negative. The patient's brain natriuretic peptide (BNP) was mildly elevated to 134 and D-dimer was elevated to 263. The patient's computed tomography (CT) scan of the chest did not show any evidence of pulmonary embolus and showed resolution of past emboli. Because of the history of previous pulmonary embolisms, the patient was admitted for continued monitoring and workup of her chest pain.   

High-sensitivity cardiac troponin T (hs-cTnT) has been introduced as a highly sensitive and early biomarker of myocardial damage. 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). A 2014 study from Sweden evaluated the significance of undetectable troponin levels and electrocardiograms (EKGs) which did not show signs of ischemia in patients presenting to the ED with chest pain. 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. They conclude that all patients with chest pain who have an initial hs-cTnT level of less than 5 and no signs of ischemia on an EKG have a minimal risk of MI or death within 30 days, and can be safely discharged directly from the ED.

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 ED observation unit. 

In this case, this patient presented to the hospital complaining of chest pain and shortness of breath. This occurred after she ate a dinner consisting of fried food. The pain was described as burning and positional. The patient's troponins trended were within normal limits while her D-dimer was elevated.  The patient's EKG did not show any ST segment abnormalities suggesting myocardial injury. The patient's EKG also did not show any changes commonly seen with pulmonary embolus and right ventricular strain. Based on review of the chart and the medical literature, the inpatient admission is not considered medically necessary for this patient. The patient's care could have been provided in an observation unit.  

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

The carrier's denial of coverage for the inpatient hospital admission should be upheld. The medical necessity is not substantiated.