Diagnosis: Chest Pain

Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was upheld.

This is a male patient with a history of hypertension, congestive heart failure, hyperlipidemia, transient ischemic attack, sepsis, hypothermia, anxiety, alcohol abuse, and right hip replacement. He presented to the Emergency Department (ED) with complaints of chest pain and high blood pressure. Cardiology consulted on the patient. It was reported that the patient had walked from another hospital after being discharged. An electrocardiogram was performed that revealed normal sinus rhythm with sinus arrhythmia. Troponin levels were drawn with negative results. The patient was negative for an acute coronary syndrome and was discharged.

This patient presented with chest pain and a history of hypertension. Utilizing the HEART score, he was considered low risk (3 points).(1) Utilizing the Thrombosis in Myocardial Infarction (TIMI) risk score, he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1).(2) Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al.(2) Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as 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 (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. Ultimately, this patient underwent myocardial perfusion imaging that revealed no evidence of ischemia- confirming the aforementioned low risk stratification. In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. It was reasonable to treat the patient at a lower level of care.

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 admission is upheld. The medical necessity is not substantiated.