Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pulmonic Valve Stenosis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a history of hypertension, gastroesophageal reflux disease (GERD), headaches, anxiety disorder and moderate-severe pulmonic valve stenosis. Per chart review, the patient had recent complaints of palpitations, headaches, and pain at the base of his neck. He underwent an elective balloon valvuloplasty procedure of the pulmonic valve. This procedure was successful and reduced the gradient across the pulmonic valve from 40-45 millimeters of mercury (mmHg) (per cardiac catheterization report) to 12-15 mmHg. After this procedure, the patient was admitted to the hospital. His condition was stable, and he was deemed appropriate for hospital discharge. At issue is the medical necessity of an inpatient stay.
The inpatient hospital stay was medically necessary for this patient who underwent a pulmonic valvuloplasty procedure. Per a review of available documentation and review of the medical literature, this patient's pulmonic valvuloplasty procedure to treat his moderate-severe pulmonic stenosis appeared to meet appropriateness criteria as documented in guidelines and relevant articles, (1-4). According to the 2008 American College of Cardiology/American Heart Association (ACC/AHA) adult congenital heart disease recommendations for intervention in patients with pulmonic stenosis, a symptomatic patient with pulmonic stenosis needs to have doming of the valve, peak gradient across valve greater than or equal to (>=) 50 millimeters of mercury (mmHg)mmHg, and a mean gradient across valve greater than (>) 30 mmHg to qualify for pulmonic valvuloplasty (1,2). Therefore, if the patient's palpitations were due, at least in part, to the  pulmonic stenosis, then the criteria for pulmonic valvuloplasty were met for this patient (1,2). Additionally, the criteria for a successful pulmonic valvuloplasty procedure - reduction of the peak gradient to less than (<) 20 mmHg - was also met in this case (1). This was a technically successful procedure for this patient. According to a review of the medical literature, the pulmonic valvuloplasty procedure is generally well tolerated (1). A mortality rate of 0.2 percent and major complication of 0.6 percent were reported by the Valvuloplasty and Angioplasty of Congenital Anomalies registry (4). Acute complications are generally minor and include a vagal response, catheter induced ventricular ectopy, right bundle branch block, and transient or permanent high grade atrioventricular (AV) nodal block (2,3). Other complications include pulmonary valve regurgitation, tricuspid regurgitation, stroke, syncope, pulmonary artery rupture, pulmonary edema, cardiac perforation, and tamponade (1-4). This patient did not experience any of these possible, significant complications in the peri-procedural period. However, the possibility of these complications that can be associated with pulmonic valvuloplasty may have contributed to the treating physician's recommendation to admit this patient overnight.
Per a search of the medical literature pertinent to length of hospital stay after a pulmonic valvuloplasty procedure, there are no current society guidelines that specify which adult patients could be discharged the same day of the procedure versus the patients that might benefit from overnight observation. Without guidelines that specifically make recommendations regarding the length of stay after this type of procedure in an adult patient, it is up to the individual physician to determine the medically necessary length of stay for his/her patient in this scenario. To make this determination, the physician may rely on previous personal experience in caring for post-valvuloplasty patients or on the medical literature for guidance on the length of stay after this procedure that has been documented at other hospitals and cardiology practices (5,6). One study referenced a 2 day hospital stay for patients post-pulmonic valvuloplasty (5). An additional study documented a post-procedure recommendation of 8-12 hours of bedrest after pulmonic valvuloplasty (6). From a website from Johns Hopkins University, Hopkins.org, information on this website for patients undergoing valvuloplasty stated "you will most likely spend the night in the hospital after your procedure. Depending on your condition and the results of your procedure, your stay may be longer" (7). Based on the information provided, the inpatient stay was medically necessary in this case.