Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea on exertion
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a male with transient ischemic attack (TIA) / cerebral vascular accident (CVA) transferred for cardiac catheterization and percutaneous coronary intervention (PCI). Symptoms were dyspnea on exertion. Co-morbididites included congestive heart failure (CHF), peripheral vascular disease (PAD), obstructive sleep apnea (OSA), hypertension, hyperlipidemia, cerebral vascular accident (CVA) and paroxysmal atrial fibrillation (PXAF). On multiple medications, he was morbidly obese.

The patient underwent uncomplicated cardiac catheterization, with percutaneous coronary intervention (PCI) using intravascular lithotripsy. Admitted to telemetry, his post catheterization recovery was uneventful and he was discharged on optimal medical therapy.

No, inpatient hospital admission was not medically necessary; the level of care was not necessary nor provided.
Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the patient was transferred in a hemodynamically state, and remained so throughout his stay. His catheterization was for revasculaiztion of a known lesion and was not for acute coronary syndrome. The patient's exam and cardiac findings were normal. His biomarkers and electrocardiogram (EKG) showed no evidence of acute ischemia. His chest x-ray (CXR) had no abnormality.  The physicians' treatment did not reflect any serious concern about any change in the patient's cardiac condition.  

Cardiac catheterization is considered an outpatient procedure. That includes care with percutaneous coronary intervention (PCI), shockwave, and femoral access as long as patient remains stable (as in this case).

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only cardiac care post procedure provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care.  This patient could be managed in an outpatient setting and is consistent with guidelines and usual community practice. This patient had known evidence of coronary artery disease (CAD).  While there is always a potential for an adverse event, one did not happen, and no actual complex treatment was added. There are no examples of care requiring inpatient level of care. The possible complications listed in the appeal letter are potential adverse consequences, but they did not occur.

Milliman criteria requirements for admission for unstable angina were not fulfilled as there was never any evidence of acute coronary syndrome (ACS) present. Criteria for an unstable patient were also not met. All testing and therapy would be appropriate, safe and guidelines consistent in a lower level of care.  Inpatient level of care was not medically necessary.

This denial explanation was consistent with guidelines and usual community care.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appropriate level of care determination based on sound medical judgement is in best of interests of the patient.