Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is the case of a patient that was transferred for coronary artery bypass graft surgery (CABG).  The patient presented to an outside hospital with complaints of chest pain and cardiac catheterization demonstrated a 70% left main coronary artery occlusion and multivessel coronary disease.  Past medical history was significant for multiple myocardial infarctions and previous coronary stent implantation, diabetes mellitus, hypertension, stroke, right ventricular thrombus, severe pulmonary hypertension and heart failure with reduced ejection fraction (25-30%) with moderate mitral regurgitation. On arrival to the hospital, vital signs were stable (blood pressure 138/75, pulse 59). A physical exam revealed a systolic murmur of mitral regurgitation,  bilateral lower extremity edema. 12 lead electrocardiogram revealed sinus rhythm with old inferior and anterior myocardial infarction. Standard preoperative testing prior to coronary artery bypass graft surgery was performed. Repeat echo demonstrated an left ventricular ejection fraction (LVEF) of 31-35% with mild to moderate mitral regurgitation (MR) and tricuspid regurgitation (TR) and mild to moderate pulmonary hypertension.  Lower extremity duplex was within normal limits. Carotid artery duplex demonstrated occlusions between 16 and 49% bilaterally. Neurology clearance prior to planned surgery transpired and magnetic resonance angiography (MRA) demonstrated diffuse severe intracranial atherosclerotic lesions as well as an acute right anterior pontine stroke. The patient was treated with dual antiplatelet therapy and CABG was postponed.  

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with chest pain and multivessel coronary artery disease including a 70% left main coronary artery lesion. The patient's pretest probability of coronary artery disease is high (Reference 1).  The patient had an intermediate HEART (History, ECG, Age, Risk Factors, Troponin) score and evaluation for coronary artery bypass surgery was indicated (Reference 2). Patients requiring circulatory support, multivessel revascularization and left main coronary artery revascularization are considered high risk and cannot be managed at a lower level of care (Reference3-4). Inpatient admission for work up and treatment was medically necessary. This patient was ultimately diagnosed with severe obstruction of the left main coronary artery and was a good candidate for bypass surgery.  Unfortunately, the patient was diagnosed with an acute stroke during the preoperative work up and bypass surgery had to be postponed.  In conclusion, full inpatient hospital admission was medically necessary in this patient with an acute coronary syndrome and multiple co-morbidities.
Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is substantiated.