Diagnosis: Heart disease
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

This is a man who presented to the hospital for scheduled cardiac catheterization and percutaneous coronary intervention (PCI). The patient's medical history was remarkable for hypertension, diabetes and hyperlipidemia. A cardiac catheterization had shown multi-vessel disease. Bypass graft surgery was recommended but the patient declined. During the procedure, PCI was performed for obstruction in the distal right coronary artery/posterior descending artery and for a chronic total occlusion of the first obtuse marginal artery. The procedure was uncomplicated. Post-procedure, the patient was admitted to the hospital. He was discharged the following day.

The inpatient hospital stay was not medically necessary.

This patient presented for scheduled percutaneous intervention after cardiac catheterization performed approximately three weeks prior showed multi-vessel disease. He was clinically stable at presentation. The procedure was uncomplicated. While some period of observation immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. The 2009 Expert Consensus Document From the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment (interval between ventricular depolarization and ventricular repolarization) elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications.

This patient met none of these criteria. Moreover, per the 2018 update to this document, patients who undergo uncomplicated PCI, including PCI for a chronic total occlusion, can be observed until they are at their baseline functional and mental status and their comorbidities are stable and then discharged. An inpatient level of care is not medically necessary in the absence of serious procedural complications or ST segment elevation myocardial infarction.