Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post staged percutaneous coronary intervention (PCI)
 
Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial upheld.

This patient is a male with a past medical history of hypertension, hyperlipidemia, diabetes mellitus and status post NSTEMI with a previous cardiac catheterization done in mid-2019. At that time the report indicates percutaneous coronary angiogram/drug eluting stent (PTCA/DES) of proximal left anterior descending artery (LAD), mid LAD and stent to ostial D1. The left main had a less than 20% stenosis. Prior to this admission the patient had presented to his physician complaining of chest pain on exertion. He initially underwent diagnostic angiogram  at another hospital and was offered PCI versus coronary artery bypass graft (CABG) but he refused surgery. Subsequently he was transferred for staged PCI. Echo done revealed preserved left ventricular (LV) systolic function with septal knuckle measuring 1.4 CM without evidence of  left ventricular outflow tract obstruction (LVOTO). His left ventricular ejection fraction (LVEF) was 65%, right ventricle (RV) was normal in size and function, left atrium was normal and had a mitral inflow pattern consistent with impaired LV relaxation and mildly elevated left atrial pressure. 

Following his coronary angiogram, the patient had DES X2 in the proximal right coronary artery (RCA), PTCA of the mid-RCA, DES to the distal RCA. This was done through a right radial approach. The patient was admitted to the hospital overnight to a telemetry unit. No events occurred overnight, his radial site was stable without hematoma or bleeding. The patient will continue to take aspirin 81 mg daily and Brilinta 90 mg twice a day. He will continue to take Lisinopril and atorvastatin as well. Because of residual disease the patient is scheduled to return for staged PCI in five weeks.

Investigators from a hospital system examined the safety of same-day discharge ambulatory PCI [percutaneous coronary intervention] in patients according to age, creatinine, and ejection fraction (ACEF) scores. The ambulatory PCI group consisted of all PCIs with same-day discharge, while the overnight-stay group consisted of all elective PCIs with in-hospital observation and discharge the following day. These investigators conclude that in this single-center registry, patients who underwent same-day discharge ambulatory PCI had no worse outcomes, and in some cases better outcomes, than overnight-stay patients; this result was found in the group as a whole, as well as in all ACEF score subcategories. (3)

This patient was electively admitted to the hospital for a coronary angiogram and staged PCI. Although the patient did note occasional chest pressure, the amount of time between the original angiogram and the staged PCI was significant and suggests that neither the physician nor patient thought that this was urgent. At the time of this admission, the patient was asymptomatic and had no complaints. The diagnostic angiogram was uncomplicated as were the PCI's. During the patient's hospital stay the patient had no complaints and there was no evidence of any abnormal findings, including the right radial artery access site. There were no changes in the patient's EKGs. This patient's care could have been provided in a less intense setting and this statement is supported by the literature cited. Acute inpatient admission to a telemetry unit was not medically necessary for this patient. The health plan acted reasonably with sound medical judgment.
 
Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.