Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.  

This female patient has a history of obesity, hypertension, and coronary artery disease (CAD) status post triple coronary artery bypass grafting (CABG). On this admission, the patient presented for a left heart catheterization following an abnormal stress test. The patient was admitted post-atherectomy after a stent was placed in the left main coronary artery. In addition, the patient had percutaneous transluminal coronary angioplasty (PTCA) of the circumflex coronary artery. 

An echocardiogram showed mild left ventricular hypertrophy (LVH). A myocardial perfusion stress test was abnormal with medium-term mild mid anterolateral ischemia. The left ventricular ejection fraction (LVEF) was normal at 69%. A stress electrocardiogram (EKG) showed ischemic changes. The patient did not experience chest pain and, compared to a previous study, the current study revealed that there was no significant change in perfusion. 

The patient's coronary angiogram was described as showing a right dominant coronary circulation. There was a 99% stenosis in the mid-left main coronary artery and a 99% stenosis in the distal left anterior descending (LAD). There was a diffuse 60% stenosis in the circumflex and a 99% stenosis in the proximal right coronary artery (RCA). There was a 100% stenosis in a graft to the mid-LAD. A successful drug-eluting stent with rotational atherectomy and intravascular ultrasound was performed on the 99% lesion in the mid-left coronary artery. A balloon angioplasty was performed on the 99% lesion in the circumflex and following intervention there was a 50% residual stenosis. After the catheterization, no shortness of breath or acute distress was noted; the patient had stable vital signs. The patient's right groin catheterization site had a clean dressing was dry and intact. There were no signs of bleeding drainage for hematoma. Recommendations included aspirin and Plavix.

Studies have been done and guidelines written to indicate that selected patients can safely be sent home after several hours of post procedure monitoring. Since it is now standard practice that patients having a diagnostic angiogram are discharged on the same day, unless they have a complication, most of the current literature pertains to patients having a diagnostic angiogram followed by a percutaneous coronary intervention (PCI). 

In this case, this patient came to the hospital for an elective coronary angiogram, which was followed by PCI because of the findings. The patient had no complaints of chest pain or shortness of breath either before or following this procedure. The patient's EKG did not show any ST segment elevations or depressions suggesting myocardial injury. There were no reported abnormalities noted during her telemetry monitoring. Based on the review of the medical record and literature, full hospital admission was not medically necessary for this patient. The literature indicates that this patient may have been observed at an observational status as long as there were no complications, such as chest pain, shortness of breath or arrhythmia. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is not substantiated. The carrier's denial of coverage for the inpatient hospital admission is upheld.