Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease; chest pain 
Treatment: Inpatient admission 
The inpatient admission was not medically necessary; inpatient level of care was neither indicated nor provided. 

This is a male with known coronary artery disease (CAD), hypertension, and hyperlipidemia who had five months of fatigue on exertion and chest pain. He was not treated with beta blockers. He was scheduled for an elective cardiac catheterization; indication was listed as "non-ACS" with angina equivalent, this was performed through the right radial artery and led to a successful placement of stent to the right coronary artery (RCA). There were no complications. 

The patient was admitted to telemetry where he had intravenous (IV) fluids and routine post percutaneous coronary intervention (PCI) care. He was discharged the next morning on optimal medical therapy. 

This was an elective, uncomplicated catheterization and PCI that was scheduled after a five month history of dyspnea on exertion in the setting of previous CAD. The patient was always hemodynamically stable with normal vital signs, normal EKG, normal left ventricular (LV) function, and no ectopy. The only care given after the uncomplicated radial catheterization was monitoring, IV fluids, and routine medications. This can be performed safely in outpatient care without any indication for a higher level. Many institutions protocols include a same day discharge. Centers for Medicare and Medicaid (CMS), Recovery Audit Contractors (RAC) surveys, proposed a two midnight rule and all guidelines specify this as an outpatient procedure for an uncomplicated PCI. 

Radial artery catheterization was developed with one of its advantages being the safety in early ambulation and discharge. An overnight stay for observation and telemetry does not change that determination. While possible, bleeding post radial artery intervention is rarely 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 that required in this patient's care post catheterization; 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' need for close monitoring; however, there were no treatment or medical care that required any status above observation in this case.  

Milliman criteria requirements for 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 (Canadian Cardiovascular Society Class III), as patient was pain free without evidence of "marked limitation of physical activity" and stable symptoms for five months. EKG showed no changes, and no acute medical treatment given for acute coronary syndrome (ACS). The patient's post PCI care was routine. 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. 

The denial is consistent with guidelines and usual community care. Post cardiac care as described is routinely performed at a lower level of care.