Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease
Treatment: full hospital admission
The insurer denied coverage for full hospital admission
The denial is upheld

This patient that presented to the hospital complaining of chest pain and shortness of breath. Past medical history was significant for hypertension, diabetes mellitus, and chronic kidney disease. Upon arrival to the hospital, vital signs were stable (Blood Pressure 115/65 mmHg (millimeters of mercury), Pulse 82 bpm (beats per minute)). Chest pain developed while the patient was driving and was exacerbated with exertion. Pain lasted for seven hours. Physical examination revealed no abnormal findings. A12-lead electrocardiogram (ECG) revealed normal sinus rhythm with T (interval of ECG) wave inversions in the lateral leads. Serum blood testing revealed an elevated creatinine 2.7mg/dl (milligrams per deciliter) and mildly elevated Troponin 0.035ng/ml (nanogram per milliliter). The patient was admitted to the hospital for further evaluation.
Echocardiogram revealed preserved LVEF (left ventricular ejection fraction) of 55-60% (percent). She underwent cardiac catheterization and non-obstructive coronary artery disease was noted. Medical therapy was prescribed, and the patient was discharged home.

The health care plan acted reasonably, with sound medical judgment and in the best interest of the patient. Full hospital admission was not necessary for this patient that presented with chest pain. Her pretest probability of coronary artery disease is intermediate (Reference 1). Utilizing the HEART (history, ECG, age, risk factors, troponin) score, she was considered intermediate risk (5 points) (Reference 2). Risk assessment of patients presenting with chest pain and no significant ST (interval of ECG) changes on ECG was reviewed by Hedayati et al. (Reference 3). Using the HEART score risk stratification schema, this patient would have an intermediate 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. These findings are concerning and warrant management and evaluation that includes serial troponin measurement, echocardiography and ischemia work up prior to discharge. However, numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care (References 4,5). They found no significant difference in outcome at 30 days between the two groups. Fernando Bellolio et al. noted that patients presenting with chest pain, that were managed in an observation unit, had similar 30-day myocardial infarction rates as those admitted to the hospital (Reference 5). Admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been managed at a lower level of care.

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