Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Coronary artery disease
Treatment:  Inpatient admission
The Inpatient admission was not medically necessary.

The patient is a male with known CAD (coronary artery disease) and hx (history) of previous stenting.  He was admitted for an elective cardiac catheterization and PCI (percutaneous coronary intervention).  He had risk factors of hypertension, DM (diabetes mellitus), hyperlipidemia, and previous MI (myocardial infarction).  The patient admitted to recent hx of left-sided chest pain and tightness.  He had a known allergy to contrast dye, and he was pre-treated. 

The left iliac artery was selected as the access site.  The catheterization was performed, and stents were placed in LAD (left anterior descending) and diagonal coronary arteries.  The sheath was removed, and vascular closure device was applied.  No complications occurred, and good results were noted. 

The patient was admitted to telemetry, and he was prescribed IVF (intravenous fluids) and routine post-PCI care.  No events were noted overnight, and the patient was discharged on optimal medical therapy.

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care.  This is best reflected in the presentation, physical exam findings, and laboratory orders and their results.  It is highlighted in the orders for care. 

In this case, the patient's symptoms were unlikely to be representative of acute coronary syndrome (ACS).  His pain was only with exertion, and there was no documentation of symptoms limiting his usual activity.  The presentation does not meet criteria for CCS (Canadian Cardiovascular Society) grade IV.  The patient's exam and cardiac findings were normal.  Biomarkers and EKG (electrocardiogram) showed no evidence of acute ischemia.  CXR (chest x-ray) was normal.  Pre-Cath orders did not include medical therapy for ACS, such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV NTG (nitroglycerin).  The catheterization and PCI were performed without complications.

The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care.  The only cardiac care provided was telemetry, which is frequently performed in a lower level of care.  The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care.  There was no complex care that required inpatient care, and no actual treatment was added. The known contrast allergy was treated with IV fluids and medications.  His documented ASA (American Society of Anesthesiologists) 3 score is standard for all patients requiring catheterization; this only represents the increase potential risk of an event, but no complication happened, and no extra care was required.  As noted above, his hx was not consistent with the label of CCS IV.

Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS present.

This was an elective, scheduled intervention that was performed successfully without complications.  All of the testing and therapy that were provided would have been appropriate, safe, and guidelines-consistent in a lower level of care.  Thus, inpatient level of care was not medically necessary.  Many institutions perform this particular procedure on this patient type as same day discharge.

The denial explanation was consistent with guidelines and usual community care.