Diagnosis: Chest pain and Substance use.
Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned.

This is a male patient with a history of hypertension, diabetes, and asthma who presented to the hospital with palpitations and chest pain following cocaine use. Upon presentation, the patient was hypertensive and tachycardic. Other findings on physical examination were unremarkable. The patient's electrocardiogram (EKG) revealed sinus tachycardia without acute ST or T wave abnormalities. The patient's serum troponin level was elevated. The patient was admitted to the hospital for observation and treatment.

Based on the review of the medical record and literature, inpatient hospital admission was medically necessary for this patient. This patient presented with chest pain and positive serum troponin. The patient's pretest probability of coronary artery disease was intermediate 1. Utilizing the History, Electrocardiogram, Age, Risk factors, and Troponin (HEART) score, the patient was considered intermediate risk 2.

Using the HEART score risk stratification schema, this patient would have an intermediate 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. These findings are concerning and warrant inpatient level of care and management. Cocaine use is associated with vasospasm, poorly controlled hypertension and myocardial infarction 4. In conclusion, given the patient's presentation and multiple cardiac risk factors in the setting of active cocaine use, inpatient hospital admission was medically necessary for this patient.

The health plan did not act 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 overturned. The medical necessity is substantiated.