Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Peripheral artery disease.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a with known peripheral artery disease (PAD), who presented to the hospital for a planned intervention.  Comorbidities include valvular heart disease, seizure disorder, diabetes, and weakness.  Outpatient Doppler flow studies confirmed the presence of significant PAD.  The patient underwent successful, uncomplicated revascularization of right leg by femoral approach.  He recovered post procedure without incident or need for further intervention.  The patient was discharged the next morning on medical therapy and planned cardiology follow-up. 

No, inpatient level of care was not medically necessary.

This was an elective, planned, uncomplicated catheterization and percutaneous transluminal angioplasty (PTA) with drug coated balloon that was scheduled.  The patient had signs and symptoms of PAD; confirmed by physical exam and Doppler flow study.  The patient was always hemodynamically stable with normal vital signs, normal electrocardiogram (EKG), and no reported ectopy.  Right femoral groin site was stable, and no hematoma or bleeding was documented.  The only care given after the uncomplicated peripheral catheterization and treatment was monitoring, intravenous fluids (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.  Centers for Medicare and Medicaid Services (CMS), Recovery Audit Contractor (RAC) surveys, proposed two midnight rule and all guidelines specify this as an outpatient procedure for an uncomplicated peripheral intervention.  

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care.  This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care.  In this case, the patient's cardiac condition was stable.  No unplanned treatment or testing were necessary.

The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care.  The only care provided post procedure was telemetry, frequently performed in a lower level of care.  The patient was admitted for monitoring, and subsequent tests and therapy did not require an inpatient level of care.  There was no complex care that required inpatient admission.  As listed in the appeal, admission was for "femoral checks, neurovascular checks, cardiac monitoring and post procedure stabilization".  These are routine procedures not requiring inpatient level of care.  Since all testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care, the inpatient level of care was not medically necessary.

Per Milliman Criteria, the patient does not qualify for Ambulatory Surgery Exception.  The patient had stable valvular heart disease, and cardiac status was also stable, neither required any inpatient level of care.