Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.  The denial is upheld. 

This is a female patient who was electively admitted to the hospital for cardiac catheterization and coronary angiogram due to complaints of intermittent left sided chest pain which was associated with dyspnea on exertion. The patient had percutaneous coronary intervention (PCI) with a drug-eluting stent to a 70% stenosis of the proximal left circumflex, PCI with a drug-eluting stent to an 80% stenosis of obtuse marginal (OM) 2 and PCI with a drug-eluting stent to the ostial left anterior descending artery. No complications occurred. Post procedure the patient was admitted to telemetry for continuous telemetry monitoring

A 2013 meta-analysis of studies reported outcomes of patients discharged on the same day as PCI. (1) These authors concluded that in selected patients undergoing largely elective PCI, same-day discharge was associated with a low rate of major complications and appeared to be as safe as routine overnight observation. In their discussion, they mention that in fact, 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 PCI.

A study done in 2014 (2) reviewed 188 cases, with 93 discharged the same day and 95 after overnight stay following elective PCI. It was concluded that in the population studied, same-day discharge after PCI is safe and feasible.

Investigators from the Mount Sinai Medical Center in New York examined the safety of same-day discharge ambulatory PCI in patients according to age, creatinine, and ejection fraction (ACEF) scores. These investigators conclude that in this single-center registry, patients who underwent same-day discharge ambulatory PCI had no worse outcomes, and in some cases better outcomes, than overnight-stay patients; this result was found in the group as a whole, as well as in all ACEF score subcategories. (3)

The evolution of PCI has led to improved safety and efficacy, such that overnight observation can be avoided in some patients. Investigators sought to provide a narrative review of the recent literature regarding the outcomes of same-day discharge (SDD) PCI and to describe a framework for the development of an SDD program. A literature search of PubMed was performed for the outcomes of same-day discharge (SDD) PCI on SDD PCI published in English from January 1, 1995, to July 31, 2015. The review, included reports of randomized clinical trials, observational studies, meta-analyses guidelines, and consensus statements in a narrative review. Compared with overnight observation, there was no increase in adverse events (bleeding, repeat coronary procedures, death, or rehospitalization) among patients in these studies who were discharged on the same day of their PCI procedure. Same-day discharge was associated with significant cost savings and was preferred by patients. (4)

This patient was electively admitted to the hospital for a coronary angiogram, and possible intervention, after a workup, which included a nuclear stress test, showed area of myocardial ischemia. This patient's care could have been provided in a less intense setting and this statement is supported by the literature cited. 

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

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