Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease (CAD)
Treatment: Full hospital admission

The insurer denied coverage for full hospital admission.
The denial is upheld.

This patient has a past medical history including hypertension, hyperlipidemia, and diabetes. He was admitted for percutaneous coronary intervention (PCI), having previously undergone diagnostic cardiac catheterization abroad. That diagnostic catheterization revealed three vessel coronary artery disease (CAD), with 75% stenosis of the left anterior descending (LAD) artery, 99% (percent) stenosis of the circumflex (CFX) with collaterals, and 70% and 90% stenoses of the right coronary artery (RCA). He had been offered coronary artery bypass grafting (CABG) and declined.

His admission history and physical (H&P) indicated planned PCI, with unremarkable exam, vitals, and electrocardiogram (EKG) other than right bundle branch block. PCI of the LAD and RCA was performed and was reportedly successful and uncomplicated. He indicated that "The patient requires continued acute level monitoring post procedure to allow for rapid evaluation and treatment as needed and is at high risk for adverse events for the reasons discussed below." However, there were no reasons discussed below in that document. 

The health care plan acted reasonably and with sound medical judgment in this case. While the patient clearly has severe coronary artery disease, it was stable disease, and the intervention was reportedly unremarkable and without unusual complications. There were no features of this intervention in the submitted documentation that place it in an unusually high-risk category other than the known three vessel coronary artery disease. The patient was stable enough to travel from abroad for a scheduled elective procedure and arrived from the community with no active symptoms or other unstable findings. No evidence of instability arose during or after his procedure.

Inpatient admission was not medically necessary for the patient. Multiple studies have evaluated the need for overnight observation after uncomplicated PCI, including the Discharge trial  and the Stride  study, and they have consistently favored same-day discharge. I do note, however, that both of these trials evaluated patients after radial access, which is typically preferred for PCI given its lower risk of complications.  (In this case, the radial and ulnar arteries were evaluated in the submitted documentation and found to be adequate, although the radial approach was not used.) Importantly, the Discharge trial specifically included patients who were considered high-risk. Additionally, a study looking at elderly patients (a different high-risk category than the patient) also showed no increased risk with discharge on the day of procedure when compared to overnight observation. 

Finally, UpToDate does not actually indicate that higher-risk patients benefit from overnight stay; it only indicates that lower-risk patients can be safely discharged. The relevant quotation appears to be "We believe it is reasonable to discharge elective, lower-risk patients following uncomplicated, lower complexity PCI after four to eight hours of observation on the day of PCI if no complications or concerns have arisen." There is no mention of higher-risk patients, although the associated reference  is a meta-analysis which does include higher-risk patients. Additionally, one could argue that the patient represented an elective lower-risk patient following uncomplicated PCI, meeting most of the descriptors in the UpToDate article. Finally, as noted above, same-day discharge is appropriate even for higher-risk patients.

For these reasons, an ambulatory hospitalization status was appropriate, and there was no information in the submitted documentation that supported an inpatient level of hospitalization.

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.