Diagnosis: Chest Pain.
Treatment: Inpatient Hospital.

The insurer denied coverage for inpatient hospital.

The denial is upheld.

This case of a gentleman that presented to the hospital complaining of palpitations and chest pain while walking in the street. Past medical history is significant for hypertension. Upon arrival to the hospital, vital signs were stable, BP (blood pressure) 169/82 mmHg (millimeters of mercury) and pulse 109 beats per minute. No abnormal findings were reported on physical examination. A 12-lead electrocardiogram (EKG) revealed normal sinus rhythm, left ventricular hypertrophy with strain. Serum blood testing revealed no significant elevation in high sensitivity troponin level (20ng/L [nanogram per liter]). The patient was admitted to the hospital for observation and treatment. Echocardiogram revealed a preserved left ventricular ejection fraction of 65-70% (percent) and left ventricular hypertrophy.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. This patient presented with chest pain and palpitations. He had a past medical history of hypertension. His pretest probability of coronary artery disease was low (Reference 1). Utilizing the HEART (history, EKG, age, risk factors, 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 (interval on EKG) changes on EKG 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 (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 insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.