electrocardiogram Review for Inpatient Denial

Case Study: Chest Pain, Non-cardiac can be Difficult to get Admission Status Correct

Chest pain is one of the most common ER diagnoses. For those patients who require hospital admission, getting the admission status correct and paid by the insurance company can be tricky. One such case involved a patient who arrived in the ER with chest pain presumed due to unstable angina (TIMI 3). The patient was admitted and spent three days in the hospital undergoing extensive testing which revealed the chest pain to be non-cardiac in nature. The case was denied by the insurance company but overturned after a Peer-to-Peer discussion with AppriseMD.

“Chest pain accounts for approximately 7.6 million annual visits to emergency departments (ED) in the United States, making chest pain the second most common complaint [1]. Patients present with a spectrum of signs and symptoms reflecting the many potential etiologies of chest pain.”

–          UpToDate


A 54-year-old male patient arrived in the emergency room with left-sided chest pain and left neck pain that had been occurring all day and intermittently for the previous 6 months. He rated the severity of pain at the time as an 8/10. The patient reported feeling short of breath on exertion with nausea, vomiting, dizziness, and weakness. The patient denied melena, fever, hearing loss, leg swelling, dysuria, gait problems, pallor headache or confusion. He took an aspirin twice on the day of admission. The patient had a history of hypertension, dyslipidemia, asthma, arrhythmia and underwent an incomplete stress test in the previous year. He also reported having 1-2 drinks daily and was vaccinated for COVID.

In the emergency room, an EKG was ordered as well as laboratory testing, echo, a chest X-Ray, IV fluids, a beta blocker, Zofran, aspirin, and morphine. The patient’s vital signs were:

  • Blood pressure 110/160 – 152/96
  • Heart rate of 57-93
  • Respiratory rate 13-17
  • Temperature of 97.9-98.2 F
  • Oxygen saturation of 94-97% on room air

Labs were:

  • WBC 8.13
  • Hgb 15.8
  • Na 128/132
  • K 3.5
  • BUN 8
  • Cr 0.82
  • Troponin x 4 <0.06,
  • Respiratory Filmarray negative
  • Hepatic panel AST 123, ALT 67


Denied Inpatient Stay

On hospital day 2 the patient’s pain was resolved but inpatient care was considered appropriate due to the ongoing cardiac workup. The patient was on a nitro drip and underwent a coronary angiogram. Although there was no evidence of severe coronary artery disease, the patient continued to require hospital level of care for  medical management and further evaluation. However, the insurance company denied the inpatient stay stating that records did not show:

  • Test results showing heart damage
  • The need for heart surgery
  • Symptoms at rest
  • Severe problems with blood pressure
  • Irregular heartbeat
  • Breathing problems

The insurance company stated the stay was more appropriate for observation.


Peer-to-Peer Discussion

After the initial denial by the insurance company, a robust Peer-to-Peer discussion was held between AppriseMD and the insurance company’s medical director. The patient’s cardiac testing was essentially normal, the symptoms resolved, and the chest pain was determined to be non-cardiac in nature. However, the denial was overturned based on the following:

  1. This was believed to be unstable angina on admission
  2. There was intensive emergent therapy including a nitroglycerin drip
  3. There was need for invasive diagnostic evaluation (cardiac catherization)

Chest pain cases that are found to be due to causes other than frank ACS can often be difficult for inpatient level of care approval. We believe that these cases often involve significant hospital resources as well as significant treating physician concern. Clear and honest discussions about the admitting clinicians’ concerns, plan of care, and resources used can help get to the most appropriate level of care.



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