Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Non-ST-elevation myocardial infarction (NSTEMI)
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned
 
This is an adult with a past medical history which includes diabetes mellitus. She presented to the emergency department (ED) with 2 days of intermittent palpitations, dizziness, and fatigue. She denied chest pain or shortness of breath. She noted a cough ongoing for 6 weeks. There were various laboratory abnormalities noted, including hypokalemia, elevated blood glucose, and elevated troponin of 165.9. There were no ischemic electrocardiogram (EKG) changes but left ventricular hypertrophy (LVH) was noted. Her workup was normal, including stress testing and echocardiography, although troponin remained elevated. 

The patient had an admission diagnosis of non-ST-elevation myocardial infarction (NSTEMI). Troponin was reported as elevated (and was, in fact high at 165.9). EKG showed LVH but no ischemic findings. Admission to telemetry was arranged.

A hospital admission was appropriate. When deciding on admission from the ED, the HEART score (History, Electrocardiogram (EKG), Age, Risk Factors, and Troponin) is commonly used. This score has been clinically validated and is described as "an internationally accepted risk stratification tool." The patient had a HEART score of 4 (one point each for history, age, risk factors, and troponin). This score is considered moderate risk, and associated with a 12-17% likelihood of MACE (major adverse cardiac event) over the following six weeks, and would have led to a recommendation for "the potential consideration of observation and further testing" from the ED.

For type 1 Myocardial Infarction (MI), admission, and cardiac catheterization with revascularization as necessary are standard treatment. This was a reasonable likelihood in this case at the time of admission. Fortunately, the workup was reassuring.

Alternatively, if type 2 MI was diagnosed, hospitalization still would have been warranted. The appropriate treatment for a type 2 MI is to treat the underlying condition. While the underlying condition in this case was never uncovered, initial concern for an underlying arrhythmia, particularly a ventricular tachyarrhythmia, was warranted. Her troponin was elevated, and she was having palpitations. The troponin itself was not explained, particularly its persistent elevation without suspected infarction. Common conditions to explain this finding include renal failure, heart failure, sepsis, pulmonary embolism, or other conditions such as advanced age - none of which were present in this case. 

Inpatient admission was medically necessary. Troponin elevation with normal EKG was consistent with non ST elevation myocardial infarction (NSTEMI). The workup and intervention for this condition is typically intensive and prolonged. She was discharged to home immediately upon completion of a reasonable workup, minimizing her time in the hospital.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is substantiated.