Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea on exertion
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult male. He was admitted for an elective catheterization and possible PCI (percutaneous coronary intervention). His symptoms included dyspnea on exertion (DOE). He has a history of STEMI (ST-elevation myocardial infarction), hypertension, and VT (ventricular tachycardia).

The patient's CTA scan revealed the presence of an LAD (left anterior descending) lesion. EKG (electrocardiogram) showed sinus bradycardia, anterior Q waves without acute ischemic changes; unchanged from previous tracings. 

Radial artery catheterization was performed without complications. LAD was stented x 3. LVEDP (left ventricular end-diastolic pressure) was normal at 10. 

The patient was stable post procedure, without chest pain or SOB (shortness of breath). Bedrest for six hours was ordered, and the patient was admitted to telemetry. IV fluids and standard post-PCI therapy were ordered. The treating physician noted, "patient to be maintained as an outpatient in a bed for extended recovery."

This was an elective, uncomplicated catheterization and PCI that was scheduled after a positive CTA that revealed LAD disease. The patient was always hemodynamically stable, with normal vital signs, normal EKG, normal LV (left ventricle) function, and no ectopy. The only care that was given after the uncomplicated radial artery catheterization was monitoring, IVF, and routine medications. This allows safe outpatient care without any indication for a higher level. Many institutions protocols include a same day discharge.  

CMS (Centers for Medicare and Medicaid Services), RAC (recovery audit contractor) surveys, the proposed two midnight rule and all guidelines specify this as an outpatient procedure for an uncomplicated PCI.  The treating physician noted, "patient to be maintained as an outpatient in a bed for extended recovery." This is consistent with common community care.

Radial artery 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. Six-hour bed rest is rarely required, and many protocols have discharge within four hours or less.

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. 

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. EKG showed no changes, and no acute medical treatment given for ACS.
 
Moderate (or conscious) sedation is a common medical intervention that does not require inpatient care to administer or recover. Routinely, patients are discharged home after their procedure.

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.