Diagnosis: Chest Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is the case of a patient that presented to the hospital with chest pain and shortness of breath. Pain was intermittent for a three-month period but on the day of presentation pain was more severe (8/10) and radiated to the left scapula. Past medical history was significant for gastroesophageal reflux disease (GERD). On arrival to the hospital vital signs were stable(Blood pressure 142/106, Pulse 89). No abnormal findings were noted on physical examination. 12 lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST or T wave abnormalities. Serum troponin levels were not elevated. The patient was admitted to the telemetry ward for monitoring and treatment. Serial troponins remained negative. The patient was treated with proton pump inhibitor medication and discharged with cardiology follow up.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. This patient presented with atypical chest pain and a past medical history GERD. The patient's pretest probability of coronary artery disease was low (Reference 1). Utilizing the HEART (History, ECG, Age, Risk Factors, Troponin) score, the patient 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 (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.

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

The medical necessity for inpatient admission is not substantiated.