Diagnosis: Chest pain on exertion
Treatment: Inpatient admission
Inpatient level of care was not medically necessary.
This patient underwent evaluation for surgery that revealed coronary artery disease (CAD). Symptoms were present for six months and the patient was electively admitted. Radially performed, he had a successful procedure without complications.

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care.

In this case, the symptoms were present for six months and discovered during routine pre op evaluation. Exam and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. CXR was normal. Echocardiogram showed no wall motion at rest. Orders did not include medical therapy for acute coronary syndrome (ACS) such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG). The review of procedure did not show other deviation from standard care. Uncomplicated radial artery approach led to placement of left anterior descending (LAD) stent.

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only cardiac care provided post procedure was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no complications that required inpatient care. While there is always a potential for an adverse event, one did not happen and no actual inpatient treatment was added.

Milliman criteria requirements were not fulfilled as there was never any evidence of ACS present. The patient did not have unstable angina as symptoms present for six months and when ischemia was discovered led to an elective approach.

No evidence was presented that any of the care could not "be managed in an outpatient setting". Per the standard in the community, catheterizations and PCIs are routinely performed an outpatient setting.

All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.