Diagnosis: Chest pain and headache
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This patient has a past medical history of diabetes mellitus and hypertension and presented to the hospital complaining of a severe headache and intermittent chest pain. Chest pain was described to be pleuritic in character. On arrival to the hospital, vital signs were stable (blood pressure 168/96, pulse 100). Physical examination revealed no major abnormality. 12 lead electrocardiogram (EKG) revealed sinus rhythm with no evidence of ischemic ST (interval on EKG) or T (interval on EKG) wave abnormalities and poor R (interval on EKG) wave progression. Serum troponin level was mildly elevated (4.62). Computed Tomography (CT) of the chest revealed coronary artery disease (CAD) with calcified plaque and 70% (percent) luminal narrowing causing occlusion of the left anterior descending artery. The patient was treated with antihypertensive medication.

This patient presented with atypical chest pain and a past medical history of hypertension and diabetes mellitus. Although the patient had calcified CAD on the CT of the chest, the patient did not present with an acute myocardial infarction (MI). The pretest probability of CAD was low (1). Utilizing the HEART (history, EKG, age, risk factors, initial troponin) score, the patient was considered low risk (2). Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score, the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days (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 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. This patient could have been treated at a lower level of care and in fact was medically stable for transfer to another facility for cardiac catheterization.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The medical necessity for the inpatient hospital stay is not substantiated.