Diagnosis: chest pain

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission.

The denial is upheld.

This male patient has a history of hypertension, diabetes, and high cholesterol.

This patient presented with two minutes of atypical chest pain and lightheadedness. His pretest probability of coronary artery disease is low. (Reference 1) Utilizing the HEART (history, ECG [Echocardiogram] anomalies, patient age, risk factors , and Troponin) score he was considered low risk. (Reference 2) Utilizing the TIMI (thrombolysis in myocardial infarction) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST changes on electrocardiogram (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. In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care.

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 inpatient hospital admission is upheld. The medical necessity is not substantiated.