Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems-Chest Pain.
Treatment: Inpatient Hospital.
The insurer denied Inpatient Admission.
The denial is upheld. 

This is a male patient, who presented to the hospital for a scheduled cardiac catheterization and possible percutaneous coronary intervention for complaints of worsening exertional chest pain over the prior two to three months and an abnormal cardiac stress test. His medical history was remarkable for coronary artery disease, hypertension, hyperlipidemia, and type 2 diabetes mellitus. Coronary angiography revealed multi-vessel disease including left main coronary artery disease (LMCA). The patient's left ventricular ejection fraction and left ventricular end diastolic pressure were normal. Stenoses in the mid LMCA and proximal left circumflex artery were treated with atherectomy and placement of drug-eluting stents. The procedure was uncomplicated. The patient was admitted to the hospital. His troponin I level was less than 0.01 nanograms (ng)/milliliters (ml). He remained stable overnight, without chest pain or acute electrocardiographic changes. He was discharged.
At issue is the medical necessity of the Inpatient Admission.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Inpatient Admission was not medically necessary for this patient.
This patient presented for elective cardiac catheterization and percutaneous coronary intervention. He was stable upon presentation, without chest pain or acute ischemic electrocardiographic changes. The procedure was uncomplicated. His serum troponin level was elevated the day after the procedure, but there was no documentation of ischemic changes on his electrocardiogram or by imaging, nor were there procedural issues that would have caused acute vessel occlusion.
While some period of observation immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, an 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 segment (ST) segment 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 an observation status following PCI for a number of reasons, including atherectomy and complex interventions, such as in this case. In this instance, however, an admission for overnight observation did not require an inpatient level of care.
Therefore, the requested health service/treatment of Inpatient Admission was not medically necessary.