Chest Pain denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested medical services on an emergent or urgent basis. Findings: The physician reviewer found that at issue in this case is whether a prudent layperson in the patient’s circumstances would have sought immediate medical attention. California law defines an “emergency medical condition” as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patient’s health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) a consultation with a cardiac electrophysiologist, (2) heart magnetic resonance imaging (MRI), (3) electrocardiogram, and (4) blood tests (TSH T3, T4, TSH - thyroid stimulating immunoglobulin, N-terminal pro-B-type natriuretic peptide (NT-proBNP), troponin T, and plasma ceramides). Researchers note that while second opinions in general internal medicine may lead to the establishment of a new diagnosis in a small proportion of patients, second opinions have value as new treatments are often initiated and patients may report improved symptomology. In this case, the patient has a history of two syncopal episodes, chest pain, and resolved atrial septal defect (ASD).

Where the denial was upheld

Physician 1: The patient is a 57-year-old woman with hyperlipidemia and complaints of chest pain and shortness of breath. In November of 2000 she underwent a cardiac catheterization, which showed “Normal left ventrical function. No angiographic evidence for significant epicardial coronary artery disease. Small distal left anterior descending either normal variant and a small eddy, although cannot rule out diffuse concentric distal left anterior descending disease to account for the patient’s apical ischemia and atypical chest discomfort.” An adverse reaction to the catheter/anesthesia is not found in the dictated report.In March 2005 she underwent a stress myoview SPECT scan. She had no ischemia. The patient is unable to tolerate statins for hyperlipidemia. Per the submitted records, she is not on cardiac medications such as beta-blocker or nitrate.

Nature of Statutory Criteria/Case Summary: An female enrollee has requested authorization and coverage for referrals to head and neck surgery, maxillofacial surgery, chiropractic, cardiology, pulmonology and a bone density test for evaluation of the enrollee’s neck pain, back pain, chest pain, and headaches. Findings: The physician reviewer found that with regard to the request for referral to head and neck surgery and referral to maxillofacial surgery, the records indicate that the patient was previously evaluated by a head and neck surgeon. This evaluation included a history, an examination, an assessment and plan. The provider did not find that the patient was a candidate for any surgical intervention and recommended treatment with corticosteroid nasal spray and salt water nasal spray. Further, the patient had subsequent imaging of the sinuses and nasal septum both with CT and MRI.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving chest pain, then check the rights and deadlines that apply to your plan.