Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea on exertion
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. He presented with dyspnea on exertion. He had an outpatient workup, which revealed an elevated calcium score. He was scheduled for an elective catheterization and possible PCI (percutaneous coronary intervention) for two weeks later. His medical history was significant for hypertension and hyperlipidemia.

The patient underwent uncomplicated catheterization through right radial approach. This revealed diffuse CAD (coronary artery disease) and placement of multiple stents. Observation in telemetry confirmed hemodynamic stability. He had bradycardia associated with beta block. He received hydration and optimal medical treatment. No overnight events occurred.

The patient was discharged in the morning without need for further intervention.

No, the Inpatient admission was not medically necessary.
This was an elective, uncomplicated catheterization and PCI (percutaneous coronary intervention) that was scheduled for two weeks after a positive calcium score. The patient was always hemodynamically stable, with normal vital signs, normal EKG (electrocardiogram), and no ectopy. The only care that was given after the uncomplicated radial catheterization was monitoring, IVF (intravenous fluids), and routine medications. This meets definition of outpatient care without any indication for a higher level. Many institutions protocols include a same day discharge.

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 not 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-catheterization care; neither 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. The appeal letter referenced the need for close monitoring of the groin due to potential complications, however, the femoral artery was not accessed nor required any observation in this case.

Milliman criteria requirements for ACS (acute coronary syndrome) do not apply, as the patient does not meet criteria to support that diagnosis. It is incorrect to label the presentation of this case as unstable angina, as patient was electively scheduled for two weeks after the results of a Calcium score, and he was pain-free, except briefly after the catheterization. His EKG (electrocardiogram) showed no changes, and no acute medical treatment given for ACS (acute coronary syndrome).

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.

The denial was consistent with guidelines and usual community care. Post-cardiac care as described is routinely performed at a lower level of care. Same day discharge has become the standard, even with multiple stents.