Appeal type: Medical necessity
Decision: Upheld

Diagnosis: dyspnea, hypertension
Treatment: Inpatient admission

The Inpatient admission was not medically necessary, as inpatient level of care was neither indicated nor provided.

The patient is a male with previous LAD (left anterior descending) PCI (percutaneous coronary intervention) six weeks prior to presentation. He was electively admitted for staged intervention. He had risk factors of hypertension, hyperlipidemia, and obesity. 

The Admit H & P (history and physical) stated no symptoms, including denial of chest pain, dyspnea, or palpitations. The patient did endorse dyspnea on exertions after four to five blocks. The patient was not on beta blockers.  

The patient underwent uncomplicated PCI to right posterior artery using right radial artery. He was hemodynamically stable, and he did not evidence acute ischemia. His EF (ejection fraction) was normal at 55 - 60%. He was continued on optimal medical therapy. He was admitted to telemetry overnight and discharged in the morning after an uneventful stay. 

This was an elective, staged, uncomplicated catheterization and PCI of RCA (right coronary artery) that was scheduled for six weeks after successful PCI of LAD. 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, 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, RAC surveys, 2 midnight rule and all guidelines specify this as an outpatient procedure for an uncomplicated PCI.  

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 provided was telemetry, which is frequently performed in observation and outpatient status. The patient was admitted for monitoring and routine post Cath 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. It is not the potential for a problem, but the actual care provided that determines level of care.

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 the patient was pain-free and denied all outpatient symptoms except dyspnea with ambulation of greater than four blocks in this morbidly obese male. The intervention was planned, not precipitated on symptoms. EKG showed no changes, and no acute medical treatment was given for ACS. The patient was not taking any beta blockers, nor was there concern of unstable angina documented. 

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.