Diagnosis: Myocardial injury

Treatment: Emergent hospital admission

The insurer denied coverage for emergent hospital admission

The denial is overturned

This patient was awoken from sleep by severe chest pain. Pain lasted for 8 hours, was accompanied by nausea and vomiting as well as dyspnea. Upon arrival to the Emergency Department (ED), vital signs were stable (Blood Pressure [BP] 139/92, Pulse [P] 74, and room air oxygen saturation 99%) and physical examination revealed no abnormal findings. The patient noted 10/10 pain that did not subside with ketorolac therapy. Electrocardiogram (ECG) revealed normal sinus rhythm without evidence of ischemic ST or T wave changes. Serial blood testing revealed an elevated and rising trend in Troponin level: 0.174, 0.251, and 0.318 nanogram per milliliter (ng/ml). The patient was admitted to the hospital for further work up and treatment. Computed tomography angiogram ruled out pulmonary embolism and aortic dissection. Echocardiogram revealed a left ventricular ejection fraction of 70-75% without wall motion abnormalities and without valvular abnormalities. Cardiac catheterization revealed no coronary artery obstruction. The patient was ultimately discharged home with follow up.

This patient presented to the hospital with severe chest pain and clear biochemical evidence of myocardial injury. Serum troponins continued to climb on three consecutive samples. Several studies have demonstrated an association between myocardial injury and poor prognosis. (2) The differential diagnosis of myocardial injury not only includes myocardial infarction but can be seen in other serious conditions such as myocarditis, coronary artery spasm and sepsis. (1) Emergent admission to the hospital for observation, diagnostic testing and treatment was medically necessary.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the emergent hospital admission is reversed. Medical necessity is substantiated.