The patient is a male with hypertension, coronary artery disease, previous myocardial infarction, coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) procedures, and diabetes. He also has ischemic cardiomyopathy, chronic systolic heart failure with an ejection fraction (EF) of 15-20%, ventricular tachycardia (VT), and previous biventricular implantable cardioverter defibrillator (ICD) placement in 2011. He was admitted for ICD generator replacement, as the device was at elective replacement time. The device was beeping, and he was sent from his physician's office to the ER to be admitted for device replacement. BP was 141/79 millimeters of mercury (mmHg), pulse 68 beats per minute (bpm), and respirations 18 in the emergency room (ER).

The health plan's determination is upheld.

Inpatient admission is not medically necessary in this case. The patient had an uncomplicated ICD generator replacement. He was hemodynamically stable on presentation to the ER - sent from an outpatient office appointment when the device was noted to be at elective replacement indicator. There were no immediate surgical complications. He did have a hematoma at the incision site, but this did not require inpatient management. He remained stable and did not require re-operation or transfusion. The patient does have multiple comorbidities, as noted above, but none of these conditions were unstable or requiring acute treatment.

Per Milliman Guidelines, the usual length of stay for electrophysiologic (EP) study and ICD implant is ambulatory to one day post-operative. In this case, the procedure is simpler than a new ICD implant, as leads were not replaced, only the generator.

Therefore, the patient could have been managed at a lower level of care status, inpatient was not medically necessary.