Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

Based on the review of the medical record, the patient was a male who was initially seen in the Emergency Department (ED) two days prior, for complaints of intermittent episodes of burning chest pain that began six days earlier. The patient reported that the sensation was consistent with an exacerbation of chronic gastroesophageal reflux disease (GERD). The patient reported that the pain started six days ago after he was eating a chocolate bar and the pain had lasted two days, which then resolved after taking omeprazole. However, the patient reported that the pain returned and prior to being referred to the ED, the patient was found to have elevated troponin of 0.42 at the urgent care center. The patient's electrocardiogram (EKG) had shown no ST elevations or depressions. However, the clinical impression was non-ST segment elevation myocardial infarction, and the plan was to admit the patient for cardiac catheterization and echocardiogram. However, the patient refused and signed out against medical advice.  

The patient then returned to the ED after being sent by his cardiologist for possible cardiac catheterization, related to the chest pain that the patient had. The patient's vital signs included blood pressure of 117/72, pulse of 72, temperature of 99.1, and respiratory rate of 16 and oxygen saturation of 99%. This patient underwent cardiac catheterization and a drug-eluting stent was placed in the proximal left anterior descending (LAD). The distal right coronary artery was noted to have a 40% stenosis.  There were no complications from this procedure. Post-catheterization, the patient was seen by Cardiology and was cleared for discharge the following day. The patient was to continue dual antiplatelet therapy with Brilinta and aspirin. The patient was also to continue atorvastatin.
	
According to the literature review, meta-analysis report indicates that over the past 15 years, numerous small, single-center observational studies and single-center, randomized, controlled trials (RCTs) have suggested favorable outcomes with same-day discharge after percutaneous coronary intervention (PCI). Studies have shown that the evolution of percutaneous coronary intervention (PCI) has led to improved safety and efficacy, such that overnight observation can be avoided in some patients. When studies compared patients who were discharged on the same day of their PCI procedure with those with overnight observation, there was no increase in adverse events (bleeding, repeat coronary procedures, death, or re-hospitalization).

In this case, the patient was sent to the ED from Cardiology for a possible angiogram because of chest pain that the patient had the prior week and was evaluated two days prior to returning to the ED. The patient had signed out against medical advice (AMA) at that time, and had no chest pain or any cardiac symptoms since then. The patient's vital signs were within normal limits and there were no abnormalities on his physical exam. The patient's lab work was normal except for his elevated troponin, and his EKG was unchanged from his recent EKG. The patient's angiogram and PCI of the left anterior descending (LAD) coronary artery were done without any complications. The patient was stable, and based on the literature review, inpatient admission was not medically necessary after the PCI intervention. The patient could have been observed for a short period of time before being discharged home. Thus, inpatient admission was not medically necessary for this patient.  

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission should be upheld. The medical necessity is not substantiated.