Diagnosis: Coronary Artery Disease

Treatment: Inpatient Admission

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

This is a male patient with a history of hyperlipidemia, depression, alcohol use, and withdrawals. He presented to the Emergency Room (ER) in early 2019 with nausea and dizziness after drinking alcohol and using marijuana. He had hypotension in the field, but was normotensive upon arrival to the ER. He was admitted for coronary artery disease and underwent a coronary angiogram. This showed non-obstructive coronary artery disease with a normal left ventricular ejection fraction. No coronary revascularization was indicated or performed. There were no procedural complications, and the patient was subsequently admitted overnight for further monitoring. He remained clinically and hemodynamically stable, and was subsequently discharged the next day to follow-up with a cardiologist.

The patient underwent an uneventful cardiac catheterization procedure with no complications, remained hemodynamically stable, was ambulatory, and was tolerating oral intake. There were no hemodynamic or clinical complications or concerns noted. Per MCG 22nd Guideline Cardiovascular Surgery or Procedure GRG: SG-CVS (ISC GRG), cardiac catheterization is an outpatient procedure. The patient did not meet inpatient admission criteria following the procedure.

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