Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital stay. 
The denial is upheld in whole. 

The patient is a male with a history of hypertension, hyperlipidemia and vertebral artery stenosis, who underwent myocardial perfusion imaging for a complaint of exertional chest pain. This showed evidence of an inferolateral infarction with peri-infarction ischemia. The next day he underwent coronary angiography. This revealed an 80% stenosis in the mid left anterior descending coronary artery and a chronic total occlusion of the first right posterolateral artery (RPLA) at its origin. Attempts to open the RPLA were unsuccessful and subsequent angiography suggested an ostial dissection. By that time, the patient had received over 300 cubic centimeter (cc) of intravenous contrast and had been exposed to 55 minutes of fluoroscopy. The procedure was terminated. The patient remained stable, without chest pain, and he was admitted to the hospital for monitoring and intravenous hydration. The next morning he was noted to have facial swelling and erythema. He denied dyspnea and had no wheezing. An allergic reaction was suspected, and he was treated with intravenous Benadryl. The swelling persisted and steroids were administered. Later on the swelling was no longer evident, and the patient was discharged. Medical necessity for an inpatient admission is at issue.

No, an inpatient stay was not medically necessary for this patient.
This patient presented to the hospital for coronary angiography after myocardial perfusion imaging was suggestive of ischemia. He was hemodynamically stable; in the records provided there is no mention of elevated cardiac biomarkers or dynamic electrocardiographic changes. He underwent an unsuccessful attempt at percutaneous coronary intervention (PCI). This was complicated by possible vessel dissection. The patient remained hemodynamically stable throughout the procedure. Post-procedure he developed facial swelling likely due to an allergic reaction. This was not associated with respiratory distress or hemodynamic compromise.
The 2009 Expert Consensus Document from the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications. This man did not meet any of these criteria. Per the recommendations, patients with vessel dissection who remain hemodynamically stable without evidence of acute infarction (such as this patient) can be admitted and monitored under a lower level of care status.
This patient developed facial swelling and erythema that was thought to be an allergic reaction to contrast dye. He remained hemodynamically stable without respiratory compromise. He responded to treatment with Benadryl and steroids. This did not require an inpatient level of care.