Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld. 

The patient is a male with history of recent MI (myocardial infarction). He presented with dyspnea. He has history of CAD (coronary artery disease), including multiple stents, MI (myocardial infarction), and hypertension.  He denied any chest pain at rest or with exercise currently. He was electively admitted for a scheduled staged intervention.

An uncomplicated right radial cardiac catheterization and stenting of distal RCA (right coronary artery) was performed. Radial band was placed, and no bleeding was noted. EKG (electrocardiogram) showed no acute ischemia, labs stable. The patient was admitted to telemetry and discharged the next morning after an uneventful night.

No, the Inpatient admission was not medically necessary.
This was an elective, uncomplicated catheterization and staged PCI (percutaneous coronary intervention) that was scheduled after a recent STEMI (ST-elevation myocardial infarction) intervention. The patient was always hemodynamically stable with normal vital signs, normal EKG (electrocardiogram), and no ectopy. 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.  Most 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 rarely 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-catheterization 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 requirements for ACS (acute coronary syndrome) do not apply, as the patient does 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, and electively scheduled. 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 be 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 routine performed at a lower level of care.