Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with hypertension and peripheral artery disease.  He underwent stress echo which was consistent for coronary artery disease (CAD). He was electively admitted for catheterization. He had evidence of two vessel coronary artery disease and underwent uncomplicated percutaneous coronary interventions (PCIs). Radial access was used the first day to stent the obtuse marginal (OM), and femoral access was used the second day for left anterior descending (LAD) intervention. The patient was admitted for "monitoring" of pain, bleeding or hematoma. No adverse events occurred and the patient was discharged the next day on optimal medical therapy.

No, the proposed treatment was not medically necessary.
These were elective, uncomplicated catheterizations and percutaneous coronary interventions (PCIs)  that were scheduled after a positive stress echo test performed months before.

The patient was always hemodynamically stable with normal vital signs, normal electrocardiogram (EKG), normal left ventricular (LV) function, and no ectopy. The only care given after the uncomplicated radial catheterization was monitoring, intravenous fluids (IVF), and routine medications.  The post femoral catheterization was also free of any complications. The required care meets the definition of outpatient care without any indication for a higher level. Many institutions protocols include a same day discharge.  Guidelines and common practice specify this as an outpatient procedure for an uncomplicated percutaneous coronary intervention (PCI).  The overnight stay for observation and telemetry does not change that determination. While possible, bleeding post intervention is not often seen, nor does it require extended monitoring.

The letter of appeal was carefully considered but it offered no evidence to support a higher level of care. The only care provided was telemetry, frequently performed in observation and outpatient status. The patient was admitted for monitoring and routine post catheterization care; neither required an inpatient level of care. There was no "complex" care required in this patient's care post catheterizations.  While there is always a potential for an adverse event, one did not happen and no actual treatment was needed. In the appeal letter it referenced Milliman Care Guidelines and the diagnosis of angina, but this was electively schedule several months after a diagnosis, and patient was stable. 

Milliman criteria requirements for acute coronary syndrome (ACS) do not apply as patient does not meet criteria to support that diagnosis. It is incorrect to label the presentation of this case as unstable angina. Electrocardiogram (EKG) showed no acute changes, and no acute medical treatment was given for acute coronary syndrome. All testing and therapy would be appropriate, safe and guidelines consistent to be in an outpatient setting. Thus, inpatient level of care was not medically necessary.

Appropriate level of care based on sound medical judgement is in the patient's best interest.