Diagnosis: Atypical chest pain

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld.

This male patient has a history of hypertension, hyperlipidemia, and tobacco abuse.

This patient presented with atypical chest pain His pretest probability of coronary artery disease is low. (Reference 1) Utilizing the HEART score he was considered low risk. (Reference 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). (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 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 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. Even though this patient had a positive stress test performed prior to presentation, there was no evidence of acute coronary syndrome.

The health plan did act 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.