Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Positive nuclear test (Cardiac/Circulatory)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. He has a history of CAD (coronary artery disease). He presented with atypical symptoms.

The patient underwent an outpatient stress test. He had excellent exercise tolerance of 12 minutes on Bruce protocol. There was a small reversible defect and he was electively scheduled for cardiac catheterization. The radial approach was used and noted a LAD (left anterior descending) lesion, which was successfully stented.

The patient did not evidence complications or hemodynamic instability. He was "monitored overnight" without incident. He was discharged the next morning on optimal medical therapy.

No, the Inpatient Admission was not medically necessary.

Inpatient level of care was not medically necessary for appropriate treatment to be rendered to the patient.

In this case, this was an elective, uncomplicated catheterization and PCI (percutaneous coronary intervention) that was scheduled after a positive nuclear test. The patient was always hemodynamically stable, with normal vital signs, normal EKG (electrocardiogram), normal LV (left ventricle) function, and no ectopy. The only care given after the uncomplicated radial catheterization was monitoring, IVF (intravenous fluid), and routine medications. This meets definition of outpatient care without any indication for a higher level. Many institutions protocols include a same day discharge. CMS (Centers for Medicare and Medicaid Services), RAC (Recovery Audit Contractor) surveys, the proposed two midnight rule, and all guidelines specify this as an outpatient procedure for an uncomplicated PCI (percutaneous coronary intervention).

Radial catheterization was developed with one of its advantages being the safety in early ambulation and discharge. The overnight stay for observation and telemetry does not change that determination. While possible, bleeding post radial artery intervention is rarely seen, nor does it require extended monitoring.

The letter of appeal was carefully considered, but it offered no evidence to support a higher level of care. The only care that was provided was telemetry, which is frequently performed in observation and outpatient status. The patient was admitted for monitoring and routine post-Cath care, neither of which required an inpatient level of care. There was no "complex" care that was required in this patient's care, post-catheterization. While there was always a potential for an adverse event, one did not happen, and no actual treatment was needed. No evidence was provided to support the statement that inpatient care was required for a favorable outcome.

Milliman criteria requirements for ACS (acute coronary syndrome) do not apply, as the patient did not meet criteria to support that diagnosis. It is incorrect to label the presentation of this case as unstable angina. EKG (electrocardiogram) showed no acute changes, and no acute medical treatment was given for ACS (acute coronary syndrome). Catheterization was scheduled electively for a week after the diagnosis was known.

All of the testing and therapy that were provided would have been appropriate, safe and guidelines-consistent in an outpatient setting. Thus, inpatient level of care was not medically necessary. ASA (American Society of Anesthesiologists) of class 3 is routine for nearly all cardiac interventions, and the majority of these are outpatients.

The denial was consistent with guidelines and usual community care. Post-cardiac care as described in this patient's case is routinely performed at a lower level of care.