Diagnosis: Chest pain.
Treatment: Inpatient admission.

The insurer denied coverage for an inpatient admission.

The denial is upheld.

This is a case of a woman that presented to the hospital with chest pain while seated in a motorized wheelchair. Relevant past medical history includes hypertension, diabetes mellitus, and stroke with residual left sided weakness. Upon arrival to the ED (emergency department) vital signs were stable (BP (blood pressure) 152/88 mmHg (millimeters of mercury) and Pulse 96 bpm (beats per minute)). Physical exam was significant for pedal edema with tense edema of the left leg and positive Homan's sign and reproducible chest pain. A 12-lead electrocardiogram (ECG) revealed sinus rhythm with heart rate of 96 bpm and no evidence of ischemic segment ST (interval on ECG) or T wave (interval on ECG) changes or right sided strain. Serum blood testing revealed no elevation in serial troponin levels (<0.012 ng/ml [nanogram per milliliter]) and an elevated D-dimer (2298 ng/ml. CT (computed tomography) angiogram was within normal limits and no pulmonary embolism was noted. Likewise, lower extremity duplex study revealed no evidence of deep vein thrombosis. The patient was admitted to the hospital for observation and treatment and ultimately discharged on medical therapy.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. This patient presented with atypical, reproducible chest pain and a past medical history of hypertension, diabetes and CVA (cerebral vascular accident). Her pretest probability of coronary artery disease was intermediate (Reference 1). She had a HEART (history, ECG, age, risk factors, and troponin) score of three and was considered low risk (Reference 2). Utilizing the TIMI (thrombolysis in myocardial infarction) risk score she 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 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.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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