Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 
Treatment: Inpatient admission. 

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

The patient is a male. He presented with left sided chest pain. He had history of CABG (coronary artery bypass graft). He underwent cardiac catheterization and PCI (percutaneous coronary intervention). 

Elective radial catheterization and PCI (percutaneous coronary intervention) was performed. The patient became hypertensive during procedure, and responded to IV (intravenous) therapy. The PCI (percutaneous coronary intervention) was successful and uncomplicated. The patient was observed overnight. He was discharged the next morning on optimal medical therapy. 

No, the Inpatient admission was not medically necessary. 

This was an elective, uncomplicated catheterization and PCI (percutaneous coronary intervention) that was scheduled six weeks after a previous PCI (percutaneous coronary intervention). The patient's hypertension was treated with IV (intravenous) hydralazine x 1. The only care that was given after the uncomplicated radial catheterization was monitoring, IVF (intravenous fluid), and routine medications. This meets definition of 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 (percutaneous coronary intervention). 

Radial 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 not seen, nor does it require extended monitoring. 

The letter of appeal was carefully considered, but it offered no evidence to support a higher level of care. The only care that was 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 did 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 except briefly and expected during inflation during the catheterization. His EKG (electrocardiogram) showed no acute changes, and no acute medical treatment given for ACS (acute coronary syndrome). 

All of the testing and therapy that were provided would have been appropriate, safe and guidelines-consistent to have been rendered in an outpatient setting. Thus, inpatient level of care was not medically necessary. 

The health plan's denial was consistent with guidelines and usual community care. Post cardiac care as described is routinely performed at a lower level of care.