Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Percutaneous coronary intervention (PCI). 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female who was electively admitted for staged percutaneous coronary intervention (PCI). In the six weeks between staged percutaneous coronary intervention (PCI), she had chest pressure and neurologic symptoms. The patient has a history of coronary artery bypass grafting (CABG), myocardial infarct (MI), peripheral artery disease (PAD), gastroesophageal reflux disease (GERD), and hyperlipidemia. She was on Plavix and aspirin (ASA). The patient's exam was significant for hypertension at 191/77. 

Percutaneous coronary intervention (PCI) with multiple stents was uncomplicated. During the procedure moderate sedation was used and intravenous (IV) beta blocker and fluids were given. The patient was admitted for monitoring post procedure and she had an uncomplicated recovery. She was restarted on her outpatient medications and discharged. 

No, the inpatient admission was not medically necessary.  The inpatient level of care was neither indicated nor provided. 

This was an elective, uncomplicated catheterization and staged percutaneous coronary intervention (PCI) that was scheduled for six weeks after initial procedures. The patient was always hemodynamically stable. Electrocardiogram (EKG) and enzymes did not show any evidence for acute ischemia. There was normal left ventricular (LV) function, and no ectopy. The only care given after the uncomplicated staged catheterization was monitoring, intravenous fluids (IVF), and routine medications. This meets definition of outpatient care without any indication for a higher level. Many institutions protocols include a same day discharge.  Center for Medicare and Medicaid Services (CMS), recovery audit contractor (RAC) surveys, and all guidelines specify this as an outpatient procedure for an uncomplicated percutaneous coronary intervention (PCI). 

This was a staged catheterization and thus anatomy and plan were known. The overnight stay for observation and telemetry does not require inpatient level of care. There were no complications that occurred that would require a higher level of care. 

The letter of appeal was carefully considered but it offered no evidence to support a higher level of care. The only post percutaneous coronary intervention (PCI) care provided was telemetry, frequently performed in a lower level of care. This patient was admitted for monitoring and routine post catheterization care; neither required an inpatient level of care. There was no "complex" care that was required in this patient's care post catheterization.  While there is always a potential for an adverse event, one did not happen, and no actual treatment was needed. Intravenous fluids (IVF) and intravenous (IV) beta blockers do not required inpatient status to treat. 

The appeal letter referenced the 24th edition of Milliman Care Guidelines as an appropriate guideline. The patient's American Society of Anesthesiology (ASA) status of three is standard for nearly all cardiac interventions and does not represent any justification for inpatient admission. 

Milliman criteria requirements for acute coronary syndrome (ACS) do not apply as the patient does not meet criteria to support that diagnosis. Electrocardiogram EKG showed no changes, and no acute medical treatment given for ACS was given. All testing and therapy would be appropriate, safe and guidelines consistent to be at a lower level of care. Thus, inpatient level of care was not medically necessary. 

The denial was consistent with guidelines and usual community care. Post cardiac care as described is routine performed at a lower level of care.