Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and dyspnea.
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

This female presented to the emergency department (ED) complaining of one year of exertional chest pain and dyspnea. Her symptoms seemed to be worsening. A cardiac stress test performed the week prior was abnormal. Her medical history was remarkable for hypertension and hyperlipidemia. In the ED, her blood pressure was 155/78 millimeters of mercury (mmHg) with a heart rate of 81 beats/minute. An electrocardiogram showed sinus rhythm without acute changes. Her serum troponin and brain natriuretic peptide (BNP) levels were normal. Chest x-ray showed no acute pathology. Her D-dimer was normal. A nasopharyngeal swab was positive for COVID-19. The patient was admitted to the ambulatory service and treated with aspirin and a statin. Her antihypertensive medications were adjusted. No treatment was deemed necessary for asymptomatic COVID (Coronavirus Disease)-19. The next day she had no complaints. Cardiac catheterization showed a left ventricular ejection fraction of 45% (percent).  There was a 95% complex lesion in the left anterior descending coronary artery (LAD) and a 95% stenosis in the diagonal artery. The mid LAD was occluded. There was a 90% distal right coronary artery stenosis (RCA). Stents were placed in the LAD and diagonal artery. The procedure was uncomplicated.  She was discharged with plans for a staged RCA intervention after two weeks. The subject under review is the medical necessity for the inpatient admission.

The health plan's determination is upheld.

Based on the documentation provided an inpatient level of care was not medically necessary.
This patient presented with worsening exertional chest pain and dyspnea. She had cardiac risk factors of hypertension and hyperlipidemia as well as a recent abnormal cardiac stress test. Thus, admission for monitoring pending cardiac catheterization was a reasonable approach. However, the patient was pain-free at rest, hemodynamically stable, with normal cardiac biomarkers and no evidence of decompensated heart failure. She did not require intensive monitoring or continuous infusion of intravenous cardioactive medications. The care this patient received pending cardiac catheterization did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be safe and is in accordance with the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE)/American College of Chest Physicians CHEST/Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT)/Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
This patient underwent cardiac catheterization and implantation of two coronary artery stents; the procedure was uncomplicated. Based on the documentation provided, an inpatient level of care post-procedure was not medically necessary. Per the 2018 expert consensus document update from the Society for Cardiovascular Angiography and Interventions, in the absence of acute ST segment elevation myocardial infarction, the majority of patients undergoing uncomplicated percutaneous coronary intervention can be discharged post-procedure once they have recovered from anesthesia, their access site is stable, and their comorbidities are at baseline status. An inpatient level of care post-procedure is not medically necessary.