Diagnosis: Coronary Artery Disease.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay. The determination is upheld.

The patient has a past history significant for hypertension, hyperlipidemia, diabetes, mild left ventricular dysfunction, prior coronavirus disease (COVID) infection and coronary artery disease with prior percutaneous coronary intervention (PCI) and presented for an elective staged percutaneous coronary intervention (PCI) of the obtuse marginal vessel. The procedure was unremarkable and a drug-eluting stent was placed without complication. The patient was admitted overnight and discharged the following day without complication.

At issue is the medical necessity of the inpatient stay.

An inpatient stay was not medically necessary in this case.

This was an elective procedure performed without complications, and the patient was discharged the following day without event. The care of this patient was most appropriate at a lower level of care. Although the patient had some risk factors that (on a population level) are associated with poorer outcomes, there were no issues related to this case that warranted an escalation of care. Specifically, there were no clinical, electrocardiogram (ECG), hemodynamic, procedural or post procedural issues that necessitated an inpatient level of care.

The care of this patient was most appropriate at a lower level than inpatient. There were no specific features related to this elective and uncomplicated PCI that warranted an inpatient level of service.