Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia.
Treatment: Inpatient hospital admission.

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

This is a male patient with a past medical history of hypertension, hyperlipidemia, non-insulin-dependent diabetes mellitus and obesity, who presented with complaints of dyspnea on exertion and dizziness for four months. The patient was status post myocardial perfusion imaging (MPI), which showed anterior lateral wall defect with reversible ischemia. He underwent percutaneous coronary intervention (PCI) of the mid ramus intermedius artery, the left circumflex artery and the first left posterolateral branch of the right coronary artery and was admitted for the management of hyperglycemia. The patient was monitored overnight and remained asymptomatic with no electrocardiogram (EKG) evidence of acute ischemia. His laboratory studies, except blood glucose, were normal.  Diabetes mellitus teaching was done and the patient was thought to be stable for discharge on day 2 of admission. 

Nascimento et al. concluded that in the population studied, same-day discharge after PCI is safe and feasible.

As per Kahn et al., investigators examined the safety of same-day discharge ambulatory PCI in patients according to age, creatinine, and ejection fraction (ACEF) scores. The ambulatory PCI group consisted of all PCIs with same-day discharge, while the overnight-stay group consisted of all elective PCIs with in-hospital observation and discharge the following day. 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.

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 recent literature. Compared with overnight observation, there was no increase in adverse events (bleeding, repeat coronary procedures, death, or re-hospitalization) 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 (Shroff et al.). 

In this case, the patient had been complaining of dyspnea on exertion and episodes of dizziness for four months. An imaging study had shown anterior lateral defects with reversible ischemia. The patient had PCI done through the radial approach with no complications. The patient's EKG studies showed no abnormalities and there was no significant elevation of his troponin level. The patient's elevated glucose levels were controlled. The patient's angiogram and PCI were done without any complications. The literature reviewed supports that this patient did not require hospital admission and could have been observed for a short period of time before being discharged home.  

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 hospital admission should be upheld. The medical necessity is not substantiated.