Diagnosis: Chest Pain.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.

This is a male patient who was transferred from the inpatient psychiatry ward to the telemetry ward after developing chest pain for 45 minutes. The patient's past medical history was significant for hypertension, alcohol abuse and attempted suicide. Upon arrival to telemetry, the patient's electrocardiogram (EKG) revealed normal sinus rhythm. The patient's serial cardiac enzymes were not elevated. The patient was ultimately transferred back to the psychiatry unit.

Based on the review of the medical record and literature, inpatient hospital admission was not medically necessary for this patient. This patient developed acute onset of atypical chest pain while lying in bed. The patient was hospitalized in a psychiatry unit due to active suicidal ideation and required constant observation. The patient's pretest probability of coronary artery disease was low.1 Utilizing the history, electrocardiogram, age, risk factors, and initial troponin (HEART- History, Electrocardiogram, Age, Risk factors, Troponin) score, the patient was considered low risk.2 Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score, the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days.3 Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (2018). 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. In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary for this patient. The patient could have been managed at a lower level of care such as an observation unit followed by transfer back to the psychiatry 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.