Diagnosis: Inferolateral ischemia

Treatment: Inpatient Admission

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

This is a male patient with a medical history of hypertension, hyperlipidemia, carotid artery disease with a stroke, persistent right-sided weakness, and a percutaneous coronary intervention (PCI). It was reported that he had been experiencing left-sided chest tightness, dyspnea and fatigue while walking for several months. Several diagnostic tests were performed. An echocardiogram that showed anterolateral hypokinesis, a dilated left ventricle, and a left ventricular ejection fraction (LVEF) of 45-50%, and a Lexiscan stress test that showed mild anterior and mild to moderate inferolateral ischemia with a LVEF of 37%. A scheduled coronary angiography with percutaneous coronary intervention was performed without complication. The procedure revealed 70-80%proximal left anterior descending (LAD) disease with a patent stent, treated with balloon angioplasty and a drug eluting stent, as well as 70-80% tandem proximal left circumflex lesions, also treated with balloon angioplasty and drug eluting stents. The dominant right coronary artery was completely occluded and left to right collaterals. He was medically stable and discharged home with outpatient follow up instructions.

There is no evidence that this patient required an acute inpatient level of care for monitoring following percutaneous coronary intervention. This could have been completed at a same-day procedure level of care. The healthcare plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.