Diagnosis: Chest Pain
Treatment: Inpatient Admission

The proposed inpatient admission was not medically necessary; inpatient level of care was neither indicated nor provided.

The patient's symptoms had been present for months. This was an elective, uncomplicated catheterization. Radial 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. While possible, bleeding post radial artery intervention is rarely seen, nor does it require extended monitoring. Many institutions protocols include a same day discharge. Centers for Medicare and Medicaid (CMS), Recovery Audit Contractor (RAC) surveys, proposed two midnight rule and all guidelines specify this as an outpatient procedure even for an uncomplicated percutaneous coronary intervention (PCI). The overnight stay for observation and telemetry does not change that determination.

Per expert recommendations, aspirin (ASA) desensitization is not required before catheterization, and if it is done, it can occur as an outpatient. There was not any medical necessity for intensive care unit (ICU) or inpatient admission for that procedure to be done safely. Also, the probability of acute revascularization was small, and many protocols are available to proceed post revascularization without ASA.

The letter of appeal was carefully considered but it offered no evidence to support a higher level of care. The only care provided was telemetry, frequently performed in observation and outpatient status. The patient was admitted for monitoring and routine post catheterization care; neither required an inpatient level of care. There was no "complex" care that required inpatient level of care in this patient's care post catheterization. While there is always a potential for an adverse event, one did not happen and no actual treatment was needed. As noted, ASA desensitization does not require a higher level of care.

Milliman criteria requirements for ACS do not apply as patient does not meet criteria to support that diagnosis. It is incorrect to label the presentation of this case as unstable angina or myocardial infarction, as patient had symptoms for months and was now pain free. Electrocardiogram (EKG) showed no changes, and no acute medical treatment given for ACS. All testing and therapy would be appropriate, safe and guidelines consistent to be in an outpatient setting. Thus, inpatient level of care was not medically necessary.

The denial was consistent with guidelines and usual community care. Post cardiac care as described is routinely performed at a lower level of care.