Diagnosis: Abnormal outpatient non-invasive evaluation, HTN, CAD
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient is a female. At the time of admission to the hospital, she had a past medical history significant for hypertension (HTN), coronary artery disease (CAD), congestive heart failure (CHF), diabetes, and peripheral vascular disease (PVD) with intermittent claudication.

The patient presented to the hospital for an elective angiogram of the lower extremities, following an abnormal outpatient non-invasive evaluation. The patient was hemodynamically stable. She underwent a peripheral angiogram with intervention/atherectomy of the left popliteal artery and tibio-peroneal trunk. There were no peri-procedural complications reported. The patient was admitted for observation post procedure with vascular and groin checks. Complete blood count (CBC) and troponin were also checked. The patient remained clinically stable and was discharged with a plan for outpatient follow-up.

This patient presented for an elective peripheral angiogram and angioplasty/atherectomy/stent of the left popliteal artery and tibio-peroneal trunk for intermittent claudication. There were no peri-procedural complications. There was no evidence of infection, bleeding, thrombosis, hematoma, access site complication, vessel perforation, acute vessel closure or any other complication related to the procedure. There was no fever. There was no evidence of hemodynamic instability. There was no report of uncontrollable pain. Usually, no acute inpatient admission is required, unless there is evidence of a bleeding or thrombotic complication, hemodynamic instability or infection. None of these complications were documented for this patient, and she was discharged home the next day in stable condition. Thus the medical record does not support medical necessity for acute inpatient care, and the services provided could have been rendered in an ambulatory setting with post-procedural observation.