Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Disorders. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned in part. 

The patient is a male with a history of coronary artery disease (CAD), previous percutaneous coronary intervention (PCI) x2, tobacco use and hypertension who was hospitalized with dyspnea and respiratory failure. He called Emergency Medical Services (EMS) with complaints of dyspnea. Paramedics started him on continuous positive airway pressure (CPAP) for respiratory distress. However, he became unresponsive and suffered a full cardiopulmonary arrest pulseless electrical activity (PEA). Resuscitation efforts were started, including cardiopulmonary resuscitation (CPR) and intubation. He achieved return of spontaneous circulation (ROSC) within 4 minutes.

The patient was admitted with a diagnosis of non ST elevation myocardial infarction (NSTEMI), resuscitated cardiac arrest, and hypertensive crisis. He was given intravenous nitroglycerin and Heparin. Aspirin, Plavix and a statin were given. Hypothermia protocol was not done as he had purposeful movements. He received intravenous Vancomycin and Zosyn for pneumonia coverage, though his leukocytosis was felt most likely reactive, due to acute NSTEMI. He was stabilized, and he was extubated and stable for transfer out of intensive care unit (ICU). Cardiac catheterization and possible revascularization were recommended. However, the patient's family declined and requested transfer to another facility for care under the patient's usual cardiologist.
The patient was transferred, where cardiac catheterization was performed. This showed a chronically occluded right coronary artery and patent proximal left anterior descending coronary stent. There was mild left circumflex disease. He was noted to have a new LBBB and electrophysiology was consulted. A loop recorder was recommended but declined by the patient. No implantable cardioverter defibrillator (ICD) was recommended. Repeat ejection fraction (EF) was 35-40%. Coreg was increased and Entresto was started. He was discharged on medical therapy including Coreg, Lasix, aspirin, Plavix, Entresto and atorvastatin.

The health plan's determination is overturned, in part. 

Inpatient admission was medically necessary, in part. The patient suffered a cardiac arrest in the setting of acute myocardial infarction and acute pulmonary edema. The patient was hospitalized with a cardiopulmonary arrest (PEA) in the setting of an acute myocardial infarction. Inpatient coronary angiography and consideration for revascularization was indicated. He was initially treated at one facility, stabilized, and transferred to another facility for coronary angiography. The inpatient admission was medically indicated in part, for coronary angiography in the setting of an acute non-ST elevation myocardial infarction, with course complicated by cardiopulmonary arrest.
However, the patient was hemodynamically stable post-catheterization. Therefore, he did not require an inpatient stay on the date of discharge and could have been treated at a lower level of care.
Per current American College of Cardiology (ACC) / American Heart Association (AHA) recommendations, inpatient cardiac catheterization is indicated in part. As the patient was intubated and not stable from a respiratory standpoint, also with concern for aspiration pneumonia, it was appropriate to perform the catheterization when it was done. Following this, he required adjustment of medical therapy, and electrophysiology evaluation for consideration for possible ICD, which was done the following day. 

The health plan's determination of medical necessity is overturned, in part.