Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.  

This is a male patient who presented to the hospital for a scheduled coronary angiogram after having an outpatient nuclear stress test which revealed evidence of ischemia. He had been experiencing chest pain and chest heaviness for one month.  He underwent a percutaneous coronary angiogram (PTCA) via a right radial approach which revealed 90% stenosis in the mid left anterior descending artery (mid-LAD) and the distal circumflex shows severe atherosclerosis and has a 20% stenosis in the proximal right coronary artery (RCA). A stent was placed in the mid left anterior descending artery (mid-LAD). The patient remained medically stable and experiences no post-procedure complications. His right wrist remained free of hematoma and neurological deficits. The patient was discharged home with instructions to follow up with his endocrinologist. 

 A study done in 2014 (2) reviewed 188 cases, with 93 discharged the same day and 95 after overnight stay following elective PCI. Baseline characteristics were similar, except for older age (73.0  7 years vs. 64.0  12 years; P<.001), more prior PCI (49.5% vs. 34.7%; P<.001), and prior coronary artery bypass graft surgery (16.1% vs. 11.6%; P=.01) in the same-day discharge group. Procedural characteristics were similar in both groups. No significant difference in the Net adverse cardiovascular events (NACE; i.e., death, myocardial infarction, stroke, target vessel revascularization, vascular complication, and major bleeding) within 48 hours' post index procedure among both groups and at 30 days was found between the groups at 48 hours (0 [0%] vs. 2 [2.1%]; P=.25) or at 30 days. They concluded that in the population studied, same-day discharge after PCI is safe and feasible.

Investigators from the Mount Sinai Medical Center in New York examined the safety of same-day discharge ambulatory PCI 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. Patients were stratified into tertiles based on ACEF score: low (<1.08), mid (greater than or equal to 1.08 and <1.31), and high (greater than or equal to 1.31). The primary endpoint was 30-day major adverse cardiac events, defined as readmission, all-cause mortality, non-fatal myocardial infarction, and target lesion revascularization. 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.

This patient was electively admitted to the hospital for a coronary angiogram, and possible intervention, after a nuclear stress test was done and showed evidence of ischemia. During the stress test the patient had no chest pain and was hemodynamically stable. His physicians apparently did not consider this a medical emergency because the elective angiogram was done almost a couple of weeks earlier. The diagnostic angiogram was uncomplicated as was the percutaneous coronary intervention (PCI) to the mid LAD.  The patient's vital signs, physical exam and laboratory studies revealed no significant changes. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital services is not substantiated.  The insurer's denial is upheld.