Diagnosis: Cardiac/Circulatory Problems.
Treatment: Inpatient Hospital.

The insurer denied inpatient stay. The denial is upheld in whole.

The patient is a male with hypertension (HTN), coronary artery disease (CAD) post coronary artery bypass graft (CABG) times three, obesity and arthritis, who was initially seen for cardiac clearance for right hip replacement.
The patient was complaining of burning sensation in his chest and shortness of breath after exertion, such as walking up the stairs or on incline. His symptoms were similar to his complaints prior to CABG.

The patient underwent coronary angiography, it revealed: 1. "Severe 3 vessels coronary artery disease (CAD). 2. Patent left internal mammary artery (LIMA) to mid left anterior descending (LAD). 3. Patent radial graft to Diagonal artery, moderate ostial disease with vasospasm). 4. Occluded saphenous vein graft (SVG) to obtuse marginal one (OM1). 5. Successful coronary intervention with drug-eluting stent (DES) implantation of the distal left main into Cx. 6. Successful coronary intervention with DES placement of the ostial and proximal to mid OM1. Angioseal was applied to right femoral artery.

The patient tolerated the procedure well. The patient's condition during and after procedure remained stable.

The health plan's determination is upheld in whole.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. The patient was evaluated for hip surgery. The patient with history of CAD and post CABG, during preoperative evaluation, was found to have exertional angina. The patient was found ischemia on his stress nuclear scan. He was scheduled for coronary angiography on elective basis. That means, there were no urgency and his angina was stable, without evidence of acute coronary syndrome. During elective admission, coronary angiography and intervention was performed. The procedure and post hospital stay was uneventful. The patient could have been managed at a lower level of care status.