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 presented to the hospital complaining of chest pain. The pain was described as intermittent lasting for 5-10-minute periods and was exacerbated by deep inspiration. Past medical history was significant for coronary artery disease and stents placed in the left anterior descending, left circumflex and right coronary arteries in the past. In addition to coronary artery disease (CAD) the patient had a history of diabetes mellitus (DM) and hypertension (HTN). Upon arrival physical examination was unremarkable, vital signs were stable. Electrocardiogram (EKG) demonstrated normal sinus rhythm. Serum blood testing revealed no abnormality and troponin was not elevated. The patient was admitted to telemetry for further testing. Pharmacologic perfusion testing revealed a preserved left ventricular ejection fraction (LVEF) 55% and no evidence of ischemia or infarction. Echocardiography revealed a preserved LVEF with no wall motion abnormalities. The patient was diagnosed with non-cardiac chest pain and released the same day.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. This patient presented with atypical chest pain. Despite his history of coronary disease, the atypical nature of the pain with no EKG abnormalities makes pretest probability of an acute coronary event very low. (1) Utilizing the HEART [history, EKG, age, risk factors, and initial troponin] score he was considered low risk (3 points).(2) Utilizing the Thrombolysis 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).(3) Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al.(3) 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 also 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. In conclusion, inpatient hospital admission was not medically necessary and this patient could have been treated at a lower level of care.

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