
201910-121800
2019
Healthfirst Inc.
Medicaid
Cardiac/ Circulatory Problems
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: Bilateral claudication
Issue under review: Inpatient admission
Determination:
The Inpatient admission was not medically necessary.
The patient is an adult female. She was admitted electively for a scheduled peripheral angiogram for bilateral claudication that had been present for five years.
This was an electively scheduled, uncomplicated, balloon angioplasty on a chronic condition. The patient had claudication for five years that was slowly progressive. There was no evidence of acute ischemic changes. The balloon angioplasty was performed successfully, and the patient was observed overnight for potential complications. There were none. Her groin site remained stable. The patient was discharged on prescribed medications with plan for a staged angioplasty on the other leg.
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. It is highlighted in the orders for care. In this case, the patient's procedure went well and her recovery was uneventful.
The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only care provided was telemetry, CPAP, IVF and a dose of an anti-emetic, all of which are frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent therapy did not require an inpatient level of care. While the patient did have multiple co-morbidities, none complicated the hospital stay.
There was no "complex" care that required inpatient level of care in this patient's care post peripheral catheterization. Her respiratory status was not unstable. This patient had no evidence of active CAD (coronary artery disease). While there was always a potential for an adverse event, one did not happen, and no actual treatment was added. CPAP was her outpatient treatment, and its use does not imply need for acute care. While she had a potential for increase bleed risk, none happened.
All testing and therapy that were provided would have been 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.