Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain.
Treatment:  Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.  The denial is upheld.

This is a male patient, who presented to the hospital for a staged percutaneous coronary intervention (PCI) of the left anterior descending (LAD) artery.  One week earlier the patient had PCI to the left circumflex (LCX) artery and obtuse marginal (OM) 1 artery.  The patient had complained of episodes of chest pain, both at rest and with exertion for the past several days.  The patient had been taking aspirin 81 mg daily and Plavix 75 mg daily at home.  His past medical history includes hypertension, hyperlipidemia, diverticulosis and gastroesophageal reflux disease (GERD). 

The patient had complained of episodes of chest pain at rest and on exertion for 2 weeks.  He was taking aspirin daily in addition to Plavix daily, and he took both on the morning of this hospital admission.  Because of this patient's multiple episodes of chest pain, the patient was thought to be having an episode of unstable angina.  The patient underwent PCI of the LAD via the right radial artery.  Post-procedure, the patient was asymptomatic and had no complaints.  The patient's access site was soft without bleeding or bruising.  The patient was told to take aspirin and Plavix daily, and to follow-up as an outpatient in one-two weeks.

A meta-analysis of studies reported outcomes of patients discharged on the same day of PCI procedure.  The study concluded that in selected patients undergoing largely elective PCI, same-day discharge was associated with a low rate of major complications and appeared to be as safe as routine overnight observation.  The study states that "over the past 15 years, numerous small, single-center observational studies and single-center, randomized, controlled trials (RCTs) have suggested favorable outcomes with same-day discharge after PCI."

The evolution of PCI has led to improved safety and efficacy, such that overnight observation can be avoided in some patients.  As per Shroff et al., "Compared with overnight observation, there was no increase in adverse events (bleeding, repeat coronary procedures, death, or rehospitalization) among patients in these studies who were discharged on the same day of their PCI procedure."

As per Rubimbura et al., "[Same-day discharge (SDD)] after successful [percutaneous coronary intervention (PCI)] without complications within the next 4-6 hours is safe and feasible in most patients with [stable ischemic heart disease (SIHD)].  Among 1,035 SDD patients treated over 10 years, only two required readmissions, and none experienced major cardiac adverse events such as death or stent thrombosis."

This patient was electively admitted to the hospital for a staged PCI after a PCI for two other vessels was done one week earlier.  This was an elective admission, which was done without any complications.  There was no indication of chest pain, arrhythmia or any concerning events that would warrant hospital admission.  There was no report of patient complaints at the time of this hospital admission.  The patient's vital signs, physical examination and laboratory studies were within normal limits.  The patient's care could have been provided in a less intense setting as per literature review. 

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial should be upheld.