Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease
Treatment: Full hospital admission
The insurer denied coverage for the hospital admission.
The denial is upheld.

This is an adult patient with a medical history that includes remote tobacco abuse, hypertension, hyperlipidemia, diabetes mellitus, obesity, obstructive sleep apnea, asthma, nephrolithiasis, and coronary artery disease with multiple prior percutaneous coronary interventions (PCIs). Despite "minimal" active symptoms and no functional limitations, the patient had a nuclear stress test, which demonstrated mild to moderate lateral ischemia and a Left Ventricular Ejection Fraction (LVEF) of 63%. 

The patient presented to the hospital, where the patient underwent left heart catheterization, which revealed two-vessel coronary disease including the left main coronary. The patient received a drug-eluting stent to the unprotected left main, and another drug-eluting stent to the 1st obtuse marginal branch of the circumflex. The patient was admitted to the hospital at that time, with normal lab work, including undetectable (normal) troponin. 

Subsequently, the day after the PCI, follow-up notes from the Interventional Cardiology Fellow, indicated that the troponin level had risen overnight to the indeterminate range, first to 0.05 in the evening, then 0.07 by the morning. There were no symptoms of concern, and the Electrocardiogram (EKG) was unremarkable. The patient was discharged to home on that day, with the notation "Though the patient was perceived as high risk for post-PCI events with expected two-night admission, the patient did well with no post-procedure chest pain, or stable cardiac enzymes or serum creatinine; thus, can be discharged home today."

The insurer acted reasonably and with sound medical judgment and in the best interest of the patient. There were no clear indications given regarding the need for inpatient treatment. The decision to admit was made at the time of the procedure, although the procedure was uncomplicated, and troponin was normal at the time of the decision.

The subsequent elevation in troponin to indeterminate levels (such as not normal, but not in the range of Myocardial Infarction) is a fairly common finding, suggesting increased medium-term and long-term risk. Some studies indicate there is no increased risk from these small elevations, while other studies suggest that troponin elevations only correlate with in-hospital complications.

Regardless, at this time, there is no consensus that these changes suggest any particular form of intervention, including extended hospitalization. The patient was discharged the day after the procedure.

The inpatient hospitalization was not medically necessary for the patient, for the reasons outlined above. Specifically, the patient had an uncomplicated procedure that did not, by itself, warrant inpatient status, and no additional factors developed subsequently that changed that determination.

In summary, inpatient hospitalization was not necessary for the patient at this time.

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 a hospital admission is not substantiated.