Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/ Circulatory Problems
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial was overturned. 

The insurer denied inpatient hospital admission for medical necessity. The denial was overturned. 

The patient is a female with a history of hypertension, hyperlipidemia, psoriasis, fibromyalgia, and Hepatitis C who reported chest pain, located substernally, described as burning and squeezing in quality, with radiation of pain to the right arm. To evaluate this anginal type chest pain, the patient underwent a stress test. This test could not be completed due to the patient's development of chest pain.
Based on this finding and the patient's anginal type chest pain, she was referred for an outpatient coronary angiogram. This revealed multi-vessel, obstructive coronary artery disease (CAD) involving proximal and mid-left anterior descending (LAD), proximal left circumflex (LCx), and mid-right coronary artery. Other arteries - diagonal branch of LAD, and obtuse marginal (OM) branches of the LCx - were found to have non-obstructive CAD. Left ventriculogram revealed a left ventricular ejection fraction (LVEF) that was abnormally low at 35-40%.
To address this the patient underwent percutaneous coronary intervention (PCI) with the placement of 3 drug-eluting stents (DES) - one to proximal LCx, and two to the proximal-mid LAD. The RCA stenosis was not stented during this procedure.
The patient did well during and after the procedure, and spent one night in the hospital. At issue is the medical necessity of an inpatient stay.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of inpatient stay was medically necessary because of the involvement of the obstructive CAD noted in the proximal LAD that necessitated drug-eluting stent placement, the multi-vessel nature of the patient's obstructive coronary artery disease, the patient's lower than normal left ventricular ejection fraction of 35-40%, and the amount of contrast (220 ml) utilized for the coronary angiography/PCI procedure.

In 2018, same day discharge (SDD) PCI was endorsed by the Society for Cardiovascular Angiography and Interventions as a safe and reasonable approach for certain PCI patients at 4 to 6 hours after the completion of elective PCI or for PCI for non-ST-segment-elevation MI, provided certain criteria are met that favor the stable patient, a successful procedure, adequate hemostasis of the access site, and strong social supports to follow through with post-PCI instructions for care (1). Exclusions for SDD-PCI were documented in a 2009 article on this topic. These exclusions included abnormal renal function, insulin-requiring diabetes mellitus, contrast allergy, presence of any chronic comorbidity, multi-vessel disease, proximal left anterior descending disease, bifurcation disease, left main disease, saphenous vein graft or internal mammary disease, and use of glycoprotein IIB/IIIA inhibitors (2).
This patient had proximal LAD, mid-LAD, and proximal LCx coronary artery stents placed during the  PCI procedure. Thus, she would meet the exclusion criteria of proximal LAD and multi-vessel disease regarding same day discharge after PCI (4).
In light of the available data on this topic, the clinical judgement of the treating physician should be heavily weighted in making a determination of same day discharge versus overnight hospitalization for a patient like this one.
For these reasons, the inpatient stay was medically necessary for this patient.