Diagnosis: Ischemia.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male admitted for scheduled catheterization and percutaneous coronary intervention (PCI). There was evidence of ischemia based on a "routine" stress test and positive perfusion study, and risk factors were present. The patient has history of coronary artery bypass grafting (CABG) and stenting as well as co-morbidities. Intervention was performed without complications. The patient was transferred to recovery for observation. Left femoral access site was stable without hematoma or bleeding. Intravenous (IV) fluids and optimal medical therapy were prescribed. The patient has an uneventful recovery and was discharged.

No, inpatient level of care was not medically necessary for safe treatment in this patient.

Appropriateness of level of care is based on the actual care provided and a patient's stability.

This was an elective, uncomplicated catheterization and percutaneous coronary intervention (PCI) that was scheduled after a positive nuclear test. The patient was always hemodynamically stable with normal vital signs, normal electrocardiogram (EKG), normal left ventricular (LV) function, and no significant ectopy. The only care given after the uncomplicated catheterization was monitoring, intravenous fluids (IVF), and routine medications. This meets the definition of outpatient care without any indication for a higher level. Many institution's protocols include a same day discharge. Centers for Medicare and Medicaid Services (CMS), and guidelines, specify this as an outpatient procedure for an uncomplicated percutaneous coronary intervention (PCI).

Best interest of patients is provided with care provided in most appropriate level of care.

The appeal letter did not provide documentation that higher level of care was medically necessary.