Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Complex cardiac history including AVR. 
CABG and PCI. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. The denial is upheld. 

No, the inpatient admission was not medically necessary, as inpatient level of care was neither indicated nor provided. 

The patient is a male. He has a complex cardiac history, including AVR (aortic valve repair), CABG (coronary artery bypass graft), PCI (percutaneous coronary intervention), dilated ascending aneurism, and previously PCI performed to open a CTO (chronic total occlusion) of proximal LAD (left anterior descending). He is now admitted for an elective, scheduled PCI of the distal part of that vessel. An uncomplicated radial approach was successfully performed. Patient was then observed post procedure and discharged on optimal medical therapy. There were no complications during hospital stay. 

This was an elective, uncomplicated catheterization and intervention performed using the radial artery access. The PCI that was scheduled as a staged procedure after a previous successful PCI of the proximal LAD one month prior. 

The patient was always hemodynamically stable with normal vital signs, EKG (electrocardiogram) without acute ischemia, mildly reduced but stable LV (left ventricle) function, and in chronic atrial fibrillation. The only care given after the uncomplicated radial catheterization was monitoring, IVF (IV fluids), and routine medications. This meets definition of outpatient care without any indication for a higher level. Many institutions protocols include a same day discharge. 

The letter of appeal was carefully considered, but it offered no evidence to support a higher level of care. The only care that was provided was telemetry, which is frequently performed in observation and outpatient status. The patient was admitted for monitoring and routine post Cath care; neither required an inpatient level of care. There was no "complex" care that was required in this patient's care post catheterization. While there was always a potential for an adverse event, one did not happen, and no actual treatment was needed. In the appeal letter, it referenced Milliman Care Guidelines and that the patient was ASA 3. Nearly all PCI procedures are ASA 3 and this represents the potential risk for serious complications, however none occurred, no treatment or intervention was needed post procedure and thus no need for inpatient level of care. While there was a significant past history of cardiac issues, all were stable and unchanged. 

Milliman criteria requirements for ACS or "surgical exception" do not apply, as this patient does not meet criteria to support those diagnosis. It is incorrect to label the presentation of this case as unstable angina, as patient was electively scheduled for one month after initial intervention. The patient had been chest pain free without dyspnea on exertion since first PCI. EKG showed no acute changes, and no acute medical treatment given for ACS. All of the testing and therapy that were provided would have been appropriate, safe and guidelines consistent in an outpatient setting. Thus, inpatient level of care was not medically necessary. 

The denial was consistent with guidelines and usual community care. Post cardiac care as described is routine performed at a lower level of care.