Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Angina
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld 

This is an adult who presented to the emergency department (ED) with chest pain and shortness of breath. His past medical history included hypertension, diabetes mellitus, hyperlipidemia, anxiety, gastro-esophageal reflux disease (GERD), and gastritis.

The presenting complaint was chest pressure associated with dyspnea on exertion, waxing and waning in severity. He was already established with a local cardiology group, and had been sent by his cardiologist to be admitted for a planned cardiac catheterization. Exam was unremarkable. Electrocardiogram (EKG) had non-specific ST and T wave abnormalities, but no ST elevations. Lab work, including troponin, was largely unremarkable. Chest x-ray was largely unremarkable. At the time of the ED evaluation, the patient was asymptomatic. A cardiology consultation was planned "given that the patient was sent in for admission." The doctor indicated "anticipate admission to the hospital for unstable angina." 

The history and physical (H&P) was similar to the above ED evaluation, noting waxing and waning exertional chest discomfort and dyspnea over the past 2 months. "Patient's cardiologist has already seen the patient and planning for cardiac catheterization in the morning." Stable angina was diagnosed.

A left-heart and coronary cardiac catheterization was performed via the right radial artery. Left ventricular ejection fraction (LVEF) was visually estimated at 25% (percent). There was mild diffuse disease, with 10-20% stenoses in the major arteries (none noted in the left main). There were no complications.

A discharge summary mentioned the admission diagnosis and unchanged discharge diagnosis of stable angina, and outlined his cardiac risk factors, reviewing that he was seen by cardiology and underwent a cardiac catheterization that was normal, and was being managed medically.

The ED physicians mentioned unstable angina, which, as an acute coronary syndrome, would have warranted a much higher level of care. However, the admission (and subsequent discharge) diagnosis of stable angina is much more consistent with the clinical presentation, as well as with the actual treatment plan and the hospital course. The fact that the patient was apparently sent for admission in order to facilitate a cardiac catheterization is supported by the fact that the patient was asymptomatic at the time of admission, and that the ED and hospitalist staffs both noted this plan in their documentation. There is no mention regarding an active clinical concern for instability.

In this context, the catheterization is essentially an elective outpatient procedure, and prolonged hospitalization is not necessary. In fact, this procedure is typically performed as an outpatient procedure. 

Cardiac catheterization is a reasonable study in this context, although the diffuse dilated cardiomyopathy suggests a non-coronary etiology making this catheterization less urgent than it might be if active ischemia was suspected.

Inpatient admission was not medically necessary for the patient. As early as the 1980s, the safety and appropriateness of outpatient cardiac catheterization was reported, in both lower-risk and higher-risk patients.

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 the inpatient admission is not substantiated.