Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

The patient presented to the hospital complaining of chest tightness on exertion and shortness of breath. Pain awoke him from sleep and radiated to his back and left arm. Accompanying symptoms included left arm and left leg weakness. Past medical history was significant for active cigarette and cocaine use, hypertension and frequent visits to the emergency department (ED) for chest pain and left sided weakness. Upon arrival to the hospital vital signs were: Blood Pressure 124/55 mmHg (millimeters of mercury) and Pulse 112 bpm (beats per minute). Physical examination revealed 4/5 strength in the left upper and lower extremity consistent with reported left sided weakness. A 12-lead electrocardiogram revealed normal sinus rhythm with atrial premature beats and left ventricular hypertrophy. Serum blood testing revealed no elevation in troponin. Urine toxicology was positive for cocaine. No ischemic abnormalities were noted. Computerized tomography (CT) angiogram of the chest was performed and no evidence of acute aortic dissection was noted. The patient was admitted to the hospital for neurologic work up. Head CT revealed nonspecific, patchy, white matter densities without evidence of acute stroke or intracranial hemorrhage. He signed out against medical advice during the neurologic work up and prior to planned cardiac ischemia work up.

This patient presented with intermittent chest pain and mild left sided weakness in the setting of active cocaine use. His pretest probability of coronary artery disease is low. (Reference 1). Utilizing the HEART (history, EKG (electrocardiogram), age, risk factors, and troponin) score, he was considered low risk (Reference 2).  Utilizing the TIMI (thrombolysis in myocardial infarction) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). Risk assessment of patients presenting with chest pain and no significant ST (interval on EKG) changes on EKG was reviewed by Hedayati et al. (Reference 3). Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (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 (cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. 

Investigators studying more than 300,000 hospital admission for chest pain in the setting of cocaine use, found that patients presenting with chest pain following cocaine and no other significant risk factors had a low risk of major adverse cardiac events and mortality. They concluded that most patients did not require hospital admission. (Reference 4). In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. 

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

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