Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease (CAD).
Treatment: Inpatient Admission.

The insurer denied coverage for the Inpatient Admission.  The denial is upheld. 

This is a male patient who had a nuclear stress test as part of an outpatient follow-up for coronary artery disease (CAD). The nuclear stress test revealed inferior and inferolateral ischemia with an ejection fraction of 42%. His home medications include metformin, Plavix, aspirin, Valspar 10, amlodipine and atorvastatin. The patient's past medical history includes hyperlipidemia, hypertension and pneumonia. The patient also has a history of myocardial infarction (MI) with previous percutaneous coronary intervention (PCI). The patient presented to the hospital for a recommended cardiac catheterization. 

A left heart catheterization and coronary angiogram was done. A progress summary stated that the patient had been received from the Cath Lab. He was alert and oriented and in no acute distress or discomfort. He denied chest pain or shortness of breath. The right radial pulse catheterization site was benign with no hematoma or swelling noted. The right radial band was in place the upper extremities were warm and mobile. 

The coronary angiogram showed an 80% in-stent stenosis in the proximal left anterior descending (LAD) artery. Laser angioplasty was done to correct this lesion. Review of the angiogram record indicates that the patient had no chest pain throughout the procedure. There were no cardiac catheterization signs and symptoms of potential problems noted. The patient was admitted to the cardiac short stay unit with the diagnosis of CAD post- operative care. Assessment of the patient following the procedure indicated that he had no chest pain or any other complaints. There were also no abnormal findings noted. His surgical site and neurovascular status were assessed. Plavix and aspirin were continued. His hemoglobin A1C was elevated at 10%. Point-of-care testing of glucose levels were assessed and treated as ordered with insulin. When all risks were addressed and the patient was hemodynamically stable, he was cleared for discharge. 

The society for cardiovascular angiography and interventions published a consensus on length of stay (LOS) following percutaneous coronary intervention (PCI). In summary, they note that most PCI that are elective and uncomplicated can be done on an ambulatory basis. Similar conclusions were published by the American College of Cardiology (ACC). 

This patient presented 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 his procedure. There were no reported abnormalities noted during his in-patient monitoring. A full hospital admission to a progressive care or telemetry bed was not medically necessary. The literature cited makes it clear that these patients may be observed as long as there were no complications, such as chest pain, shortness of breath or arrhythmia. After a period of observation these patients may be discharged home for outpatient follow-up. 

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

The carrier's denial of coverage for the Inpatient Admission is upheld.