Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe Left Main Coronary Artery Stenosis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The insurer has denied coverage for the full hospital admission as not medically necessary. In a Final Adverse Determination letter, they stated that the patient had a coronary angiogram. There were no severe problems warranting a full hospital admission. The requested admission is denied based on Milliman Care Guidelines using the guideline of Cardiovascular Surgery or Procedure (GRG: W0099). 

In an appeal letter, it is stated that the patient presented to the hospital for a scheduled cardiac catheterization. The patient underwent a left heart catheterization with left and right coronary angiogram. There was severe left main coronary artery stenosis. The patient was admitted for continuous telemetry monitoring. Cardiology recommended an emergent transfer to another facility, but the patient refused. The patient was discharged. The requested admission was warranted based on Milliman Care Guidelines 26th Edition using the guideline of General Admission Criteria (CG-GAC).

Asked to review the case of a patient with a history of hypertension, hypercholesterolemia and an elevated calcium score on computed tomography (CT) scan of the chest presented to the hospital for elective cardiac catheterization following a complaints of worsening dyspnea on exertion. Vital signs and physical examination were within normal limits. Cardiac catheterization was performed via the right radial artery and revealed a 90% (percent) stenosis of the left main coronary artery, a 50% stenosis in the proximal left anterior descending artery, a 70% stenosis in the ramus and a 90% stenosis in the first obtuse marginal artery. Left ventricular (LV) ejection fraction was 55%. No perioperative complications were noted. Arrangements were made for the patient to be transferred directly to a tertiary care center for coronary artery bypass graft surgery. The patient refused and was discharged the same day. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. This patient presented for elective cardiac catheterization. The patient underwent an uncomplicated procedure, and a recommendation was made for the patient to undergo immediate coronary artery bypass surgery. The patient was asymptomatic, hemodynamically stable and was discharged home on the same day. Several investigators have studied the safety and cost savings surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital (1-4). Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care (4).  This patient did not even undergo percutaneous revascularization and simply had an uncomplicated diagnostic study. In conclusion full inpatient hospital admission was not medically necessary. The patient could have been managed at a lower level of care.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is not substantiated.