Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with known history of coronary artery disease with 2 prior stents. He was on dual antiplatelet therapy with aspirin and Plavix. He also has a history of hyperlipidemia - on Pravastation. He found to have abnormal stress test performed for atypical chest pressure symptoms.

The patient was brought in for elective cardiac catheterization and underwent percutaneous coronary intervention (PCI) with drug eluting stent placement to OM1 (obtuse marginal branch 1). His peri- and post-procedure course was uneventful.

Per the records, the patient was admitted post-PCI (percutaneous coronary intervention) for telemetry monitoring, post-procedural care and medicine/endocrinology consult to manage elevated blood glucose of 158.

The health plan denied coverage of the inpatient admission on the basis that it was not medically necessary. The health plan posits that the patient could have been treated at an observation level of care. The treating facility appealed this decision, contending that the admission was medically necessary.

No, the Inpatient admission was not medically necessary.
The patient had abnormal stress test. Hence, he underwent cardiac catheterization and PCI (percutaneous coronary intervention) to treat obstructive OM1 (obtuse marginal branch 1) coronary artery disease. The American Diabetes Association guidelines recommends "Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold 180 mg/dL [milligrams per deciliter]. Once insulin therapy is started, a target glucose range of 140-180 mg/dL [milligrams per deciliter] is recommended for the majority of critically ill patients and noncritically ill patients." This patient is not documented to be critically ill. New-onset diabetes mellitus with recorded blood glucose 158 requiring initiation of oral hypoglycemic agents is commonly managed as outpatient in routine clinical practice.

As per expert consensus document update from the society for cardiovascular angiography and interventions, it is reasonable for this patient post-PCI (percutaneous coronary intervention) to have been admitted under observation but not higher inpatient level of care. The inpatient admission was not medically necessary. Blood glucose 158 does not increase the patient's acuity level and therefore, does not warrant inpatient admission. The American Diabetes Association guidelines recommends "Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold 180 mg/dL [milligrams per deciliter].  Once insulin therapy is started, a target glucose range of 140-180 mg/dL [milligrams per deciliter] is recommended for the majority of critically ill patients and noncritically ill patients." This patient is not documented to be critically ill. New-onset diabetes mellitus with recorded blood glucose 158 requiring initiation of oral hypoglycemic agents is commonly managed as outpatient in routine clinical practice.

The patient's Peri and post-procedure course was uneventful.  As per expert consensus document update from the society for cardiovascular angiography and interventions, it is reasonable for this patient post-PCI (percutaneous coronary intervention) to have been admitted under observation but not higher inpatient level of care. The inpatient admission was not medically necessary. Patient's clinical history suggests atypical chest pressure symptoms. There is no documentation in the medical records for unstable angina that might have otherwise warrant inpatient admission.

Therefore, given the above, the Inpatient admission was not medically necessary.

Yes, based on SCAI (Society for Cardiovascular Angiography & Interventions) recommendations on Post-PCI (percutaneous coronary intervention) length of hospital stay and American Diabetes Association Guidelines on blood glucose management, the health plan did act reasonably, with sound medical judgement and in the best interest of the patient.