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ModifiedCurativePolicy CHP-IP-2026-002

Acute Myocardial Infarction - NSTEMI / Unstable Angina

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This policy governs medical necessity for acute inpatient admission, observation or outpatient management, level-of-care assignment, continued stay, and discharge readiness for adults with NSTEMI, type 2 myocardial infarction, unstable angina, or acute chest pain undergoing evaluation for acute coronary syndrome. It applies to Curative commercial PPO and EPO members in fully insured, level-funded, and self-funded plans.

Policy Summary

PayerCurative

PolicyAcute Myocardial Infarction - NSTEMI / Unstable Angina

Policy CodePolicy CHP-IP-2026-002

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionSubmit criteria-based authorization requests for acute inpatient admission, continued stay, and level of care.

SourceLink

POLICY UPDATE CHANGES

Routine upstream glycoprotein IIb/IIIa inhibition was removed as an inpatient service because current guidance does not recommend routine use.

Adults 18+Applicable population

2-3 daysExpected stay: uncomplicated NSTEMI

1-2 daysExpected stay: unstable angina

Every 24hContinued-stay review

GRACE >140High-risk threshold

Medical Necessity and Level-of-Care Criteria

Inpatient admission

Covered acute inpatient admission when ALL of the following are met.

Clinical-severity finding: At least one of the following is present: type 1 NSTEMI with troponin rise and/or fall, at least one value above the 99th-percentile upper reference limit, and ischemic symptoms or ECG changes; new dynamic horizontal or downsloping ST depression of at least 0.5 mm in 2 contiguous leads, or T-wave inversion greater than 1 mm in 2 contiguous leads with a prominent R wave; rest angina lasting more than 20 minutes, recurrent angina despite initial anti-ischemic therapy, or crescendo angina with high-risk features; GRACE score above 140, TIMI score of 3 or more, or HEART score of 7 or more; hemodynamic instability with systolic blood pressure below 90 mm Hg, acute heart failure, new or worsening mitral regurgitation, or sustained ventricular arrhythmia; or type 2 myocardial infarction with an underlying cause that itself requires inpatient treatment.
Hospital-level service: At least one of the following is required: invasive coronary angiography planned during hospitalization; parenteral anticoagulation; intravenous nitroglycerin; continuous ECG monitoring; intravenous diuretics, vasoactive drugs, or noninvasive ventilation for associated heart failure; or inpatient treatment of the precipitating condition for type 2 myocardial infarction.
Angiography is planned within 2 hours for very high-risk features, within 24 hours for GRACE above 140 or other high-risk features, or before discharge for intermediate risk.

Policy Summary

PayerCurative

PolicyAcute Myocardial Infarction - NSTEMI / Unstable Angina

Policy CodePolicy CHP-IP-2026-002

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionSubmit criteria-based authorization requests for acute inpatient admission, continued stay, and level of care.

SourceLink

On This Page

Observation or outpatient management

Observation or emergency-department discharge with outpatient follow-up is appropriate when ANY of the following applies.

Lower-acuity disposition: Low-risk chest pain with HEART score 0-3, high-sensitivity troponin below the myocardial-infarction threshold on a validated 0/1-hour, 0/2-hour, or 0/3-hour protocol, and no ischemic ECG changes; intermediate risk with negative serial troponins, a non-ischemic ECG, resolved symptoms, and testing needs that cannot be promptly met as an outpatient; chronic stable, non-dynamic troponin elevation without new ischemic symptoms or ECG changes; or myocardial injury without ischemia managed under another primary policy.

Observation evaluation is generally completed within 24-48 hours.

Intensive care unit

ICU or cardiac ICU care is medically necessary when ANY of the following is present.

ICU level of care: Cardiogenic shock at SCAI stage C-E or any vasopressor or inotrope requirement; refractory angina despite maximal medical therapy while awaiting immediate angiography; sustained ventricular tachycardia, ventricular fibrillation, or high-grade atrioventricular block with hemodynamic compromise; acute pulmonary edema requiring invasive ventilation or noninvasive ventilation that is not improving within 1-2 hours; or a mechanical complication or temporary mechanical circulatory support.

Step-down or intermediate care

Step-down or telemetry-unit care is medically necessary when no ICU criterion is met and ANY of the following is present.

Intermediate level of care: Ongoing or recent ischemic symptoms or dynamic ECG changes requiring continuous monitoring; continuous intravenous heparin, intravenous nitroglycerin, or intravenous antiplatelet infusion; heart failure requiring intravenous diuretics with frequent reassessment or improving noninvasive ventilation; non-sustained ventricular tachycardia or new atrial fibrillation requiring rate-control titration; or the first 12-24 hours after complex PCI or observation of a femoral-access complication.

Medical-surgical unit

Medical-surgical unit care is appropriate when continued acute care is needed but no ICU or step-down criterion is met, including ANY of the following.

Medical-surgical level of care: The member is hemodynamically stable and pain-free while awaiting in-hospital angiography within the next 24-48 hours; requires post-angiography telemetry only for surveillance, transition to oral therapy, or monitoring of renal function after contrast; or requires treatment of the precipitating condition for type 2 myocardial infarction that does not itself require monitored care.

Discharge readiness

Discharge is medically necessary when ALL of the following are met.

Discharge readiness: Troponin has peaked and is declining or is at baseline, with no ischemic chest pain for at least 12-24 hours; the member is hemodynamically stable without intravenous vasoactive therapy; no high-grade or sustained arrhythmia has occurred for at least 24 hours; invasive evaluation is completed, or an ischemia-guided strategy is selected with risk stratification completed or scheduled within 72 hours of discharge; left ventricular ejection fraction has been assessed during the admission or within the prior 6 months without interval change; guideline-directed therapy has been started or contraindications documented, including aspirin, P2Y12 inhibitor when indicated, high-intensity statin, beta-blocker when indicated, and renin-angiotensin system inhibitor when ejection fraction is 40% or less or hypertension, diabetes, or chronic kidney disease is present; the member is ambulatory without symptoms, the access site is intact, and hemoglobin and creatinine are stable; and a safe transition plan is in place, including education, cardiac rehabilitation referral for NSTEMI or revascularized unstable angina, and follow-up within 1-2 weeks.Systolic blood pressure at least 90 mm Hg; resting heart rate 50-110 beats per minute.

Continued-stay criteria

Continued acute inpatient stay is medically necessary, with review every 24 hours, when ANY of the following is documented.

Continued-stay trigger: Clinically indicated in-hospital angiography is pending with a documented reason for any delay longer than 24 hours; multivessel or left-main disease is awaiting a heart-team decision or CABG during the same admission; recurrent ischemia, reinfarction, or new heart failure is present; arrhythmia requires intravenous therapy or monitoring of a new rhythm-control drug; an access-site complication or acute kidney injury requires daily management; or the precipitating condition for type 2 myocardial infarction still requires inpatient treatment.Review every 24 hours.

A stable member awaiting routine scheduling over a weekend is reviewed for level of care.

Extended-stay review

Extended-stay review applies when the stay exceeds the expected benchmark and ANY trigger is present.

Extended-stay trigger: Persistent hemodynamic instability or vasoactive support; refractory arrhythmia; recurrent ischemia or new biomarker rise; access-site bleeding requiring transfusion; contrast-associated acute kidney injury delaying angiography or requiring monitoring; CABG during the same admission; or up-titration of therapy limited by hypotension or worsening renal function.Review every 24 hours.

Expected length of stay is a planning benchmark, not a limit on covered days. The expected stay is about 2-3 days for uncomplicated NSTEMI managed with an early invasive strategy and 1-2 days for unstable angina.

Does not meet criteria

The following circumstances do not meet medical-necessity criteria and are referred for physician review.

Does not meet criteria: Inpatient admission for chest pain with HEART score 0-3, a negative high-sensitivity troponin protocol, and a non-ischemic ECG; inpatient admission solely for stable, chronically elevated, non-dynamic troponin without new ischemic findings; continued stay solely for stress testing or coronary CT angiography that could be completed within 72 hours as an outpatient in a stable member; routine glycoprotein IIb/IIIa inhibitor infusion as the only hospital-level service in a stable member; or days awaiting post-acute placement after discharge-readiness criteria are met without an acute need.

These requests are not denied by an automated system or a non-physician reviewer.

STEMI is outside the scope of this policy and is managed under Policy A001.

Acute heart failure without acute coronary syndrome is outside the scope of this policy and is managed under Policy A003.

Atrial fibrillation as the primary problem is outside the scope of this policy and is managed under Policy A005.

If new ST elevation or a STEMI-equivalent develops during the stay, manage the case as STEMI under Policy A001 with emergent reperfusion rather than routine NSTEMI or unstable-angina management.

Inpatient admission is not supported for low-risk chest pain when the HEART score is 0-3, a validated high-sensitivity troponin protocol is negative, and the ECG is non-ischemic. Observation or outpatient management with follow-up is appropriate.

A stable, chronically elevated, non-dynamic troponin level without new ischemic symptoms or findings does not, by itself, support acute inpatient care.

A continued inpatient stay solely for stress testing or coronary CT angiography does not meet criteria when the testing can be completed within 72 hours as an outpatient in a stable member.

Routine upstream glycoprotein IIb/IIIa inhibitor infusion does not support inpatient care when it is the only hospital-level service for a stable member.

Custodial days spent awaiting post-acute placement after discharge-readiness criteria are met, without an acute need, do not meet acute-care criteria. These cases are referred for physician review and discharge planning.

Diagnosis, Procedure, Revenue, and Risk-Score Coding

ICD-10-CM: NSTEMI and other myocardial infarction typesICD-10

I21.4	NSTEMI and other myocardial infarction types
I21.9	NSTEMI and other myocardial infarction types
I21.A1	NSTEMI and other myocardial infarction types
I21.A9	NSTEMI and other myocardial infarction types
I21.B	NSTEMI and other myocardial infarction types

ICD-10-CM: unstable and other anginaICD-10

I20.0	Unstable and other angina
I20.1	Unstable and other angina
I20.2	Unstable and other angina
I20.81	Unstable and other angina
I20.89	Unstable and other angina
I20.9	Unstable and other angina

ICD-10-PCS: percutaneous coronary intervention examplesICD-10

02703ZZ	Percutaneous coronary intervention (example)
027034Z	Percutaneous coronary intervention (example)
027134Z	Percutaneous coronary intervention (example)

MS-DRG: acute myocardial infarction, discharged alivemixed

280	Acute myocardial infarction, discharged alive
281	Acute myocardial infarction, discharged alive
282	Acute myocardial infarction, discharged alive

MS-DRG: angina and circulatory disorders with catheterizationmixed

286	Angina and circulatory disorders with catheterization
287	Angina and circulatory disorders with catheterization
311	Angina and circulatory disorders with catheterization

MS-DRG: percutaneous cardiovascular proceduresmixed

250	Percutaneous cardiovascular procedures
251	Percutaneous cardiovascular procedures
321	Percutaneous cardiovascular procedures
322	Percutaneous cardiovascular procedures
323	Percutaneous cardiovascular procedures
324	Percutaneous cardiovascular procedures
325	Percutaneous cardiovascular procedures

MS-DRG: coronary bypassmixed

231	Coronary bypass
232	Coronary bypass
233	Coronary bypass
234	Coronary bypass
235	Coronary bypass
236	Coronary bypass

Revenue codesRevenue

0120	Revenue code
0121	Revenue code
0122	Revenue code
0123	Revenue code
0124	Revenue code
0126	Revenue code
0127	Revenue code
0128	Revenue code
0129	Revenue code
0200	Revenue code

1–10 of 78

1/8

Applicable Revenue CodesRevenueCovered

0120	Revenue code
0121	Revenue code
0122	Revenue code
0123	Revenue code
0124	Revenue code
0126	Revenue code
0127	Revenue code
0128	Revenue code
0129	Revenue code
0200	Revenue code

1–10 of 78

1/8

HEART score

Low-risk rangeHEART score 0-3

High-risk thresholdHEART score 7 or more

Score componentsHistory, ECG, Age, Risk factors, and Troponin

GRACE score

High-risk thresholdGRACE score above 140

Invasive-care timingEarly coronary angiography within 24 hours for GRACE above 140 or other high-risk features

Risk assessment useSupports timing decisions for invasive care in non-ST-elevation acute coronary syndrome

TIMI score

Score rangeTIMI score 0-7

Low-risk rangeTIMI score 0-2

Inpatient-severity thresholdTIMI score 3 or more

Systolic blood pressure

Instability thresholdSystolic blood pressure below 90 mm Hg

Clinical significanceIndicates hemodynamic instability

Admission relevanceQualifying clinical severity finding for acute inpatient admission

Dynamic ECG changes

ST-depression thresholdNew horizontal or downsloping ST depression of at least 0.5 mm in 2 contiguous leads

T-wave thresholdT-wave inversion greater than 1 mm in 2 contiguous leads with a prominent R wave

Required characteristicThe ECG change must be dynamic

Discharge stability

Chest-pain stabilityNo ischemic chest pain for at least 12-24 hours

Rhythm stabilityNo high-grade or sustained arrhythmia for at least 24 hours

Hemodynamic stabilitySystolic blood pressure at least 90 mm Hg without intravenous vasoactive therapy

Resting heart rate50-110 beats per minute

Transition requirementsInvasive evaluation completed or an ischemia-guided strategy selected; the member is ambulatory without symptoms, laboratory values are stable, and follow-up is arranged within 1-2 weeks

GRACE score

ThresholdGRACE score above 140

Risk categoryHigh risk

Clinical applicationSupports early invasive evaluation and coronary angiography within 24 hours when applicable

Authorization and Documentation Requirements

Prior Authorization

Submit criteria-based inpatient authorization

Submit authorization requests for acute inpatient admission, continued stay, and level of care with documentation demonstrating the applicable medical-necessity criteria. Inpatient admission requires at least one qualifying clinical-severity finding and at least one required hospital-level service; continued stay requires an active qualifying condition reviewed every 24 hours.

Clinical-severity findings may include qualifying troponin changes with ischemic symptoms or ECG changes, dynamic ischemic ECG changes, high-risk scores, hemodynamic instability, acute heart failure, sustained ventricular arrhythmia, or a type 2 myocardial infarction requiring inpatient treatment.
Hospital-level services may include planned invasive coronary angiography, parenteral anticoagulation, intravenous nitroglycerin, continuous ECG monitoring, or inpatient treatment for associated heart failure or the precipitating condition of type 2 myocardial infarction.

Prior Authorization

Support the requested level of care

Assign ICU, step-down/telemetry, or medical-surgical care according to the applicable level-of-care criteria. ICU care requires at least one ICU trigger; step-down care requires no ICU trigger plus at least one intermediate-care trigger; medical-surgical care is appropriate when acute care remains necessary but higher-level criteria are absent.

ICU triggers include cardiogenic shock, vasopressor or inotrope use, refractory angina awaiting immediate angiography, hemodynamically compromising ventricular arrhythmia or high-grade AV block, nonimproving pulmonary edema requiring ventilation, or mechanical circulatory support.
Step-down or telemetry triggers include ongoing or recent ischemia requiring monitoring, continuous intravenous heparin, nitroglycerin, or antiplatelet infusion, heart failure requiring intravenous diuretics, selected arrhythmias, or the first 12-24 hours after complex PCI.

Documentation Required

Document discharge readiness

Before discharge, document that all discharge-readiness requirements are met, including clinical stability and completion or scheduling of invasive or ischemia-guided evaluation. Include the transition plan, required therapy or documented contraindications, education, applicable cardiac rehabilitation referral, and follow-up within 1-2 weeks.

Troponin must be peaked and declining or at baseline, with no ischemic chest pain for at least 12-24 hours.
Document no high-grade or sustained arrhythmia for at least 24 hours, stable blood pressure and heart rate, assessed ejection fraction, stable hemoglobin and creatinine, and ambulation without symptoms.

Documentation Required

Required clinical documentation

Include the clinical record elements needed to substantiate the diagnosis, risk level, treatment strategy, and requested care. Missing supporting documentation can prevent confirmation of medical necessity or the appropriate level of care.

Serial ECGs with timestamps.
Troponin values with assay type, 99th-percentile limit, and timing of each sample.
Documented HEART, TIMI, or GRACE score and risk category.
Selected invasive or ischemia-guided strategy and timing rationale.
Catheterization and revascularization information or stress/CT angiography results.
Ejection fraction, daily level-of-care justification, medication reconciliation, and discharge follow-up plan.

Documentation Required

Continued-stay and extended-stay support

For continued stays and days beyond the expected length of stay, document the active clinical trigger, objective supporting evidence, and treatment plan, with review at least every 24 hours. Any angiography delay longer than 24 hours requires a documented reason.

Continued-stay triggers include recurrent ischemia or reinfarction, new heart failure, arrhythmia requiring intravenous therapy, access-site complications, acute kidney injury requiring daily management, or a type 2 myocardial infarction precipitating condition still requiring inpatient treatment.
Extended-stay triggers include persistent hemodynamic instability, refractory arrhythmia, recurrent ischemia or new biomarker rise, access-site bleeding requiring transfusion, contrast-associated acute kidney injury, CABG during the same admission, or therapy up-titration limited by hypotension or worsening renal function.
Expected length of stay is a planning benchmark, not a limit on covered days.

Billing Rule

Support requested quantity and duration

Ensure that the requested quantity, units, and duration are supported by the submitted documentation. If the documentation supports only part of the request, the supported portion is approved and only the unsupported increment is reviewed.

Document the clinical basis for each requested inpatient period or unit of service.
Concurrent review applies to each continued-stay period.

Denial Risk

Low-risk or inappropriate site of care

Do not request inpatient admission or continued inpatient care for low-risk presentations that meet observation or outpatient criteria. Low-risk chest pain with HEART score 0-3, a negative high-sensitivity troponin protocol, and a non-ischemic ECG does not support inpatient admission; stable chronic non-dynamic troponin without new ischemic findings and testing that can be completed outpatient within 72 hours likewise do not support the requested care.

Consider observation or emergency-department discharge with outpatient follow-up when the applicable lower-acuity criteria are met.
Stable chronic troponin elevation without new ischemic findings does not by itself establish an acute inpatient need.

Denial Risk

Routine upstream antiplatelet infusion

Do not use routine glycoprotein IIb/IIIa inhibitor infusion as the sole basis for inpatient care in a stable member. Routine upstream glycoprotein IIb/IIIa therapy is not a qualifying hospital-level service by itself.

Document other qualifying clinical-severity findings and hospital-level services when inpatient care is requested.

Denial Risk

Custodial or post-discharge placement days

Do not continue acute inpatient days solely because post-acute placement is delayed after discharge-readiness criteria are met. Days awaiting placement without an acute need do not meet acute-care criteria and require discharge planning and physician review.

Days already authorized are not retroactively denied.

Prior Authorization

STEMI conversion

If new ST elevation or a STEMI-equivalent develops during the stay, manage the member as STEMI under Policy A001 with emergent reperfusion rather than routine NSTEMI or unstable-angina handling.

The finding changes the review pathway and requires urgent STEMI management.

Denial Risk

Unsafe discharge

Do not discharge a member with ongoing ischemia, uncontrolled arrhythmia, or rising creatinine at the planned discharge time. Discharge is unsafe in these circumstances and acute care must continue.

Reassess discharge readiness when ischemia, rhythm instability, or renal deterioration is present.

Prior Authorization

Requests failing criteria require physician review

Requests that do not meet the policy criteria must be referred for physician review rather than receiving an adverse determination from an automated system or non-physician reviewer.

Automated systems and non-physician clinical reviewers may approve a request in full or in part but may not issue an adverse determination.

Prior Authorization

Physician adverse-determination process

Only a licensed physician of the same or similar specialty may issue an adverse determination. The requesting provider must first be offered a peer-to-peer discussion, and the reviewing physician must meet applicable plan and state requirements.

The physician review process applies when a request does not meet criteria or when the unsupported portion of a quantity, unit, or duration is reviewed.
A service is not subject to adverse determination solely because the policy does not address a specific criterion; the request must be reviewed by a physician applying generally accepted standards of medical practice.

Clinical Context

Non-ST-elevation acute coronary syndromes span a broad clinical spectrum, from low-risk unstable angina that may be evaluated in observation or outpatient settings using high-sensitivity troponin protocols and structured risk scores, to NSTEMI with refractory ischemia, heart failure, or shock requiring immediate invasive management. The policy uses risk-based pathways to guide disposition and the timing of invasive evaluation.

Clinical Definitions and Risk Concepts

NSTEMI

Troponin findingA rise and/or fall of cardiac troponin with at least one value above the 99th-percentile upper reference limit

Ischemic evidenceClinical evidence of ischemia

ECG distinctionNo persistent ST elevation

Type 2 myocardial infarction

MechanismOxygen supply-demand imbalance rather than atherothrombotic plaque disruption

Examples of precipitating conditionsTachyarrhythmia, anemia, hypotension, or hypoxemia

Clinical implicationThe underlying cause determines whether inpatient treatment is required

Unstable angina

SymptomsIschemic chest discomfort at rest, of new onset, or with a crescendo pattern

Troponin findingNo troponin elevation above the myocardial-infarction threshold

Distinction from NSTEMIIschemic symptoms are present without myocardial-infarction-level troponin elevation

HEART score

Score rangeValidated 0-10 chest-pain risk score

ComponentsHistory, ECG, Age, Risk factors, and Troponin

Low-risk rangeHEART score 0-3

GRACE score

Full nameGlobal Registry of Acute Coronary Events risk score

High-risk thresholdA GRACE score above 140 identifies high risk

Clinical useUsed to support risk-based timing of invasive care

TIMI risk score

Score rangeSeven-item score from 0-7

Applicable conditionsUnstable angina and NSTEMI

Low-risk rangeTIMI score 0-2

Myocardial injury versus myocardial infarction

Myocardial infarctionRequires distinction from chronic or non-ischemic myocardial injury and is defined in the policy by ischemic context and infarction criteria

Type 2 infarctionA distinct myocardial infarction category caused by oxygen supply-demand imbalance

Chronic stable troponinChronically elevated, stable troponin without ischemia does not by itself justify admission