Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea on exertion, palpitations, and fatigue.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

No, the Inpatient admission was not medically necessary, as inpatient level of care was neither indicated nor provided.

The patient is a male. He underwent an outpatient nuclear stress test. His symptoms were dyspnea on exertion, palpitations, and fatigue. He denied chest pain. His medical history was significant for ESRD (end-stage renal disease) on HD (hemodialysis), hypertension, hyperlipidemia, and GERD (gastroesophageal reflux disease). 

The patient was electively admitted and an uncomplicated PCI (percutaneous coronary intervention) was performed. He was admitted to telemetry for "procedure care and monitoring." Hemodialysis was performed. After an uneventful recovery, he was discharged the next morning on optimal medical therapy. 

This was an elective, uncomplicated catheterization and PCI that was scheduled months after a positive nuclear test. The patient was always hemodynamically stable with normal vital signs, and no chest pain. He had no unexpected lab results and no complications from the femoral cardiac catheterization. The only care given after the uncomplicated catheterization was monitoring, IVF (intravenous fluids), 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.  An overnight stay for observation and telemetry does not change that determination. The nurses' notes confirm routine recovery.

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 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. 

While there may be factors for risk, no actual complications occurred and no inpatient level of care was necessary. Essentially all patients undergoing PCI should be symptomatic, and the lesion description only predicts potential risk. Milliman Care Guidelines do not support admission to inpatient level of care. There was no medical reason that patient could not be discharged after the procedure recovery.

Milliman criteria requirements for ACS (acute coronary syndrome) do not apply, as the patient does not meet criteria to support that diagnosis. It would be incorrect to label the presentation of this case as unstable angina, as patient was pain-free. EKG (electrocardiogram) showed no changes of active ischemia, and no acute medical treatment was given for ACS. All testing and therapy 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.