Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abnormal myocardial Perfusion.
Treatment: Inpatient Hospital Stay.
The insurer denied the inpatient hospital stay.
The denied is upheld.

This male presented to the hospital for scheduled cardiac catheterization. His medical history was remarkable for hypertension, hyperlipidemia and type 2 diabetes. He had been evaluated for palpitations. Myocardial perfusion imaging was abnormal. Cardiac magnetic resonance imaging (MRI) showed a left ventricular ejection fraction (LVEF) of 34% [percent] with regional wall motion abnormalities. Thus, the cardiac catheterization was scheduled. Upon presentation, the patient was hemodynamically stable. He denied chest pain. There were no acute electrocardiographic changes and his serum troponin I level was normal. Coronary angiography showed a chronic total occlusion of the left anterior descending coronary artery. The vessel was successfully opened and treated with two stents in the mid and distal vessel. The procedure was uncomplicated. The patient was admitted to the hospital post-procedure. He had no complaints. His troponin I level was 0.24 nanograms/milliliter (ng/ml). An echocardiogram showed an LVEF of 37%. The patient was discharged. The subject under review is the medical necessity for an inpatient hospital stay.

The health plan's denial is upheld.

Based on the records provided, an inpatient hospital stay was not medically necessary.

This patient presented for elective cardiac catheterization and possible percutaneous coronary intervention. He was stable upon presentation, without acute ischemic electrocardiographic changes. The procedure was uncomplicated.

While some period of monitoring immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. The 2009 Expert Consensus Document From the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment [the flat, isoelectric section of the electrocardiogram (ECG) between the end of the S wave (the J point) and the beginning of the T wave] elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications. This patient met none of these criteria. Per the 2018 update to this document, with the exception of patients with ST segment elevation myocardial infarction, most stable patients can be discharged post-percutaneous coronary intervention (PCI) on the day of the procedure provided they are at their baseline functional and mental status and all of their baseline comorbidities are stable. Certain patients may remain in the hospital on observation status following PCI for a number of medical reasons. This patient had an intervention for a totally occluded artery, which has an increased risk for peri-procedural complications. Thus, while admission for overnight monitoring post-procedure was a reasonable approach, an inpatient admission was not medically necessary. The patient also had an increase in his serum troponin level; however, this was not associated with chest pain, new electrocardiographic changes, or new left ventricular wall motion abnormalities. This did not require an inpatient level of care. The patient could have been safely managed at a lower level of care status.