202308-166753
2023
Healthfirst, Inc.
HMO
Cardiac/ Circulatory Problems
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
Asked to review the case of a adult with no significant past medical history that presented to the hospital complaining of chest pain, palpitations and dyspnea. The patient reported using cocaine and drinking tequila on the day prior to admission. On arrival to the hospital vital signs were stable (Blood pressure [BP] 160/71, pulse 73 beats per minute [bpm]). Physical examination revealed no significant abnormalities. 12 lead electrocardiogram (EKG) revealed normal sinus rhythm with right bundle branch block (RBBB) and nonspecific T wave abnormalities. Serum blood testing revealed no elevation of high sensitivity troponin 15 nanograms per liter (ng/L). Echocardiogram revealed a preserved left ventricular ejection fraction (EF) without wall motion abnormalities and an left ventricular ejection fraction (LVEF) of 55-60%. Computed tomography angiogram (CTA) demonstrated coronary artery disease (CAD) and a calcium score of 217. The patient was admitted to the hospital and scheduled for cardiac catheterization. Angiography demonstrated non obstructive coronary artery disease and the patient was discharged on medical therapy.
The patient pretest probability of coronary artery disease is low. (Reference 1) Utilizing the HEART score (History, electrocardiogram, age, risk factor, and troponin) he was considered low risk. (Reference 2) Utilizing the TIMI risk score (Thrombosis in Myocardial Infarction) the patient 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 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 (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.
Investigators studying more than 300,000 hospital admission for chest pain in the setting of cocaine, found that patients presenting with chest pain following cocaine and no other significant risk factors had a low risk of major adverse cardiac events and mortality. They concluded that most patients did not require hospital admission. (4). 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 hospital admission is not substantiated.