Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cardiac catheterization.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a male, who presented with palpitations and chest pain.  Original rhythm was atrial fibrillation with rapid ventricular response.  He converted to NSR (normal sinus rhythm) spontaneously.  Comorbidities included hypertension.  He was admitted with diagnosis of angina.  The exam, including vital signs, was normal.  EKG did not show acute ischemia, and cardiac enzymes were negative.  Echocardiogram showed normal LV (left ventricular) function.  A CT angiogram revealed LAD (left anterior descending artery) coronary atherosclerosis.  An uncomplicated cardiac catheterization was performed, and stents were placed in mid LAD.  Post procedure care was unremarkable.  The patient was discharged on optimal medical therapy.

No, the inpatient admission is not medically necessary. 

Determination of level of care is primarily dependent on the actual care a patient receives and whether a higher level of acuity is needed to give this care.  This is best reflected in the presentation, physical exam findings, laboratory orders and their results and highlighted in the orders for care.

In this case, the initial presentation was of atrial fibrillation with rapid ventricular rate response.  It is significant to note that despite the rapid heart rate, no significant ischemic changes were seen on EKG and enzymes were negative.  Patient spontaneously converted to sinus, and subsequent EKG did not show acute ischemia.  Exam and cardiac findings were normal.  Biomarkers and EKG showed no evidence of acute ischemia.  CXR (chest x-ray) was normal.  Echocardiogram showed no wall motion abnormality.  Past nuclear scan showed a small perfusion defect inferiorly (often artifact) and did not lead to increased medical treatment for CAD (coronary artery disease).  CT coronary angiogram did reveal intermediate LAD lesions, and a relatively low calcium score.  Patient went to Cath lab (without full medical therapy being ordered), and intermediate lesions with borderline IFR (instantaneous wave-free ration) were stented without complications.  Recovery was uneventful, and the patient was discharged on optimal medical therapy.  None of the treatments and testing performed required an admission to a higher level of care to be completed safely.  All are routinely performed in an outpatient setting.

Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS present.  The appeal letter stated that the patient met criteria for unstable angina.  That statement is not consistent with his history, exam, physical findings, test results and diagnostic criteria.  Primary symptom was palpitations.  Those symptoms and "weird" chest pain resolved with spontaneous conversion to sinus.  Patient was hemodynamically stable throughout, and treating physicians did not see the necessity of emergent electric cardioversion or urgent transfer to Cath lab.  Multiple tests for ischemia were performed that would not have been done if patient was unstable.  Admit orders did not include acute medical therapy for ACS (acute coronary syndrome), such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV NTG (intravenous nitroglycerin).  Troponins were negative, and the EKG did not show acute ischemia.  The presence of intermediate lesions does not support a diagnosis of unstable angina.  All of the testing and therapy would be appropriate, safe and within guidelines consistent to be in lower level of care.  Thus, inpatient level of care was medically unnecessary.