Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease with myocardial infarction

Treatment: Cardiac catheterization

The insurer is denied coverage for inpatient admission

The denial is upheld. 

The patient is a male who presented to his physician complaining of increasing shortness of breath with moderate exertion it had been getting worse over the past few months. The nuclear stress test done showed small partially reversible perfusion defects of the basil inferior and inferolateral walls with mild to moderate ischemia. He has a positive family history of coronary artery disease (CAD) with a history of his brother dying from myocardial infarction (MI) while he was in his 50s. A cardiac catheterization and coronary angiogram were recommended. His past medical history includes CAD with MI, diabetes mellitus, gastrointestinal (GI) bleeding and hyperlipidemia. He was admitted for a scheduled coronary angiogram and possible percutaneous coronary intervention (PCI). His vital signs were stable. The electrocardiogram (EKG) was done and showed normal sinus rhythm at 69; the PR interval (time from the onset of the P wave to the start of the QRS complex) was slightly prolonged at 232, this was a normal EKG. The lipid profile included cholesterol 357, triglycerides 458 and high density lipoprotein 44. The stress EKG was negative for ischemia. The patient's echocardiogram was done. The left ventricular size was normal. The ejection fraction was estimated to be between 50-55%. Left ventricular thickness was increased. The coronary angiogram showed two-vessel coronary artery disease. The left main showed mild luminal irregularities. The left anterior descending (LAD) showed a 40% stenosis of the proximal LAD and diffuse disease distally. D1 (first diagonal) was a small vessel and showed a 50% stenosis. The left circumflex (LCX) showed an 80% stenosis of the proximal LCX and 80% in-stent stenosis of the middle LCX stent. OM1 (first obtuse marginal) shows a 60% stenosis. The right coronary artery (RCA) was a large dominant vessel with 50% stenosis of the proximal RCA and 100% in-stent stenosis of previous stent in the distal RCA. Left heart catheterization showed the left ventricular ejection fraction (LVEF) was 60%. There was mid-basal and inferolateral hypokinesis. The left ventricular end-diastolic pressure was 10 mmHg. There was no aortic stenosis or no mitral regurgitation. A successful laser arthrectomy of the 80% stenosis of the posterior lateral circumflex and mid circumflex with a Resolute Onyx drug-eluting stent resulted in 0% residual stenosis and excellent angiographic results with thrombosis in myocardial infarction 3 flow post intervention. He was admitted to the hospital and was placed on a telemetry floor. The patient was seen and evaluated. He was hemodynamically stable and appropriate for discharge home. 

This patient was electively admitted to the hospital for a coronary angiogram, and possible intervention. The diagnostic angiogram was uncomplicated as was the PCI. The patient's vital signs, physical exam, EKG and laboratory studies revealed no significant abnormalities. As per literature review, this type of patient can have limited monitoring and then safely be discharged home. 

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

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