Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with remote history of PCI (percutaneous coronary intervention). She presented with dyspnea, and she underwent elective cardiac catheterization.

The procedure revealed multivessel CAD (coronary artery disease). CABG (coronary artery bypass graft) was recommended, but the patient declined. She was admitted for elective PCI (percutaneous coronary intervention), which was performed without complications. The patient was admitted for groin checks, IV (intravenous) hydration, labs and optimal medical therapy. Troponin was measured at 0.03, 0.07, 0.07. An episode of dizziness was treated with IV (intravenous) fluids. She was discharged on usual post PCI (percutaneous coronary intervention) medication.

No, the Inpatient admission was not medically necessary.

This was an elective, uncomplicated catheterization with PCI (percutaneous coronary intervention) that was scheduled after a diagnostic heart catheterization revealed CAD (coronary artery disease). The patient was always hemodynamically stable with normal vital signs, normal EKG (electrocardiogram), normal LV (left ventricle) function (EF [ejection fraction] 68%), and no ectopy. The only care that was given after the uncomplicated catheterization was monitoring, IVF (intravenous fluids), and routine medications. This meets the definition of outpatient care without any indication for a higher level. Many institutions protocols include a same day discharge. Guidelines specify this as an outpatient procedure for an uncomplicated PCI (percutaneous coronary intervention).  This has become common community practice.

Recent closure technique for femoral artery catheterization was developed with one of its advantages being the safety in early ambulation and discharge. The overnight stay for observation and telemetry does not change that determination.

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 and IV (intravenous) fluids, 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. Milliman criteria requirements for ACS (acute coronary syndrome) do not apply, as the patient does not meet criteria to support that diagnosis. It is incorrect to label the presentation of this case as unstable angina, as the procedure was electively scheduled. The patient was pain free and hemodynamically stable. Her dizziness responded to simple hydration. EKG (electrocardiogram) showed no changes, and no acute medical treatment was given for ACS (acute coronary syndrome). Troponins as seen do not represent a risk for immediate adverse events.

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.