Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is: Upheld

The patient is a female who presented to the hospital for scheduled cardiac catheterization for symptoms of palpitations and exertional dyspnea. Her medical history was remarkable for hypertension, hyperlipidemia, pre-diabetes, pulmonary embolism and obesity. An echocardiogram showed a left ventricular ejection fraction of 60-65%. Computed tomography (CT) scan showed a coronary calcium score of 1367. CT angiography showed probable severe stenosis in the proximal left anterior descending artery (LAD) and mild stenosis in the mid-LAD and left circumflex arteries. The cardiac catheterization was performed and revealed obstructive disease in the proximal and mid-LAD and the first obtuse marginal artery (OM). The proximal LAD lesion was treated with rotational atherectomy and a drug-eluting stent. Stents were also placed in the mid-LAD and first OM. The procedure was uncomplicated. Post-procedure the patient had an episode of chest pain without electrocardiographic changes. It resolved with acetaminophen and antacids. She remained stable overnight and was discharged. Medical necessity for an inpatient level of care is under review.

The health plan's determination is upheld.

Based on the documentation provided an inpatient admission was not medically necessary. This patient presented for elective cardiac catheterization and percutaneous coronary intervention, if warranted. She was hemodynamically stable upon presentation and the procedure was uncomplicated. 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, 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 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 observation status following PCI for a number of medical reasons such as prolonged or adverse effects from sedation, fluid or electrolyte imbalance, or ongoing pain, bleeding, ischemia, or dysrhythmia after the procedure.
In this instance, given the patient's chest pain post-procedure, admission for overnight monitoring was appropriate, however it did not require an inpatient level of care and could have been managed at a lower level of care status.