Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Moderate ischemia in the entire inferior wall and ejection fraction (EF) of 49%. 

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.  The denial upheld.

This patient is a male with a history of: hypertension, hyperlipidemia, obesity, sleep apnea, and respiratory failure with hypercapnia.  He was recently admitted to another hospital for respiratory failure that was predominantly due to COPD exacerbation with complaints of leg swelling.  He was treated with bi-level positive airway pressure (BiPAP), steroids and inhalers and initially he was given the anti-diuretic, Lasix.  He also had a computer tomogram (CT) of the chest which was unremarkable and showed no evidence of pulmonary embolus.  He had positive troponin series from demand ischemia and had outpatient follow-up with a nuclear stress test which revealed moderate ischemia in the entire inferior wall and ejection fraction (EF) of 49%.  He presents to the hospital for left and right heart catherization, and a coronary angiogram, for further evaluation.  His initial vital signs include temperature 98.1 F., heart rate 69, blood pressure 139/59, respirations 16 and oxygen saturation 98% on room air.  His body mass index (BMI) was 37.  Physical examination did not describe any abnormalities.

A 2013 meta-analysis of studies reported outcomes of patients discharged on the same day as PCI.  (1) Demographic data, procedural characteristics, and adverse outcomes were collected.  Two composite outcomes were pre-specified:  1) death, myocardial infarction (MI), or target lesion revascularization (TLR); and 2) major bleeding or vascular complications.  Data from 12,803 patients in 37 studies were collated, including 7 randomized controlled trials (RCTs) (n = 2,738) and 30 observational studies (n = 10,065).  The majority of patients in both cohorts underwent PCI for stable angina.  The vascular access site was predominantly trans radial in the randomized cohort (60.8%) and trans femoral in the observational cohort (70.0%).  In the RCTs, no difference was seen between same-day discharge and routine overnight observation with regard to death/MI/TLR (odds ratio [OR]: 0.90; 95% confidence interval [CI]: 0.43 to 1.87; p = 0.78) or for major bleeding/vascular complications (OR: 1.69; 95% CI: 0.84 to 3.40; p = 0.15).  In observational studies, the primary outcome of death/MI/TLR occurred at a pooled rate of 1.00% (95% CI: 0.58% to 1.68%), and major bleeding/vascular complications occurred at a pooled rate of 0.68% (95% CI: 0.35% to 1.32%).

This patient was electively admitted to the hospital for a coronary angiogram, and possible intervention, after a workup for an episode of pulmonary disease and troponin elevation secondary to demand ischemia occurred.  This led to a nuclear stress test that showed moderate ischemia to the inferior wall.  The diagnostic angiogram was uncomplicated as was the PCI to the proximal RCA. The patient's vital signs, physical exam and laboratory studies revealed no significant changes.  The determination is this patient's care could have been provided in a less intense setting and this statement is supported by the literature that is previously cited.  The acute inpatient admission was not medically necessary for this patient.  

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

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.