Diagnosis: Shortness of breath.
Treatment: Inpatient Hospital Stay.

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

The patient has a past medical history of hypertension, hyperlipidemia and coronary arterial disease who was referred by his cardiologist for a planned coronary angiogram given his symptoms of exertional shortness of breath and a positive nuclear stress test. On the day of admission, the patient was hemodynamically stable. He underwent coronary angiography and had a stent placed to the proximal left anterior descending artery. He was monitored overnight and discharged home in a stable condition. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of the inpatient stay is not medically necessary. This patient had stable angina symptoms and an abnormal stress test. He was referred for outpatient coronary angiography. The procedure report was reviewed in detail and there were no intraprocedural adverse events. Post procedure, he was hemodynamically stable and he had a mild hematoma at the access site that was managed appropriately. He was monitored overnight and continued to be stable. His other medical conditions remained stable as well. Based on the current standard of care and latest literature review, this patient could have been safely and effectively managed at a lower level of care.