Diagnosis: Coronary Artery Disease.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is the case of an adult female, for which an inpatient level hospitalization is under review. There was history of hypertension, diabetes, coronary artery disease (CAD), percutaneous coronary intervention (PCI), and she was admitted electively for percutaneous intervention of the left anterior descending artery (LAD). Vital signs were essentially normal. The creatinine was normal. She underwent the procedure without complication. She remained stable and was discharged.

"In terms of adverse cardiovascular outcomes, same day discharge was neither superior nor inferior to overnight hospital stay following PCI in those patients with stable CAD." (Bundhun, P. K. et al. 2017)

"Conclusion: In the population studied, same-day discharge after PCI is safe and feasible. Adequately powered randomized prospective studies are necessary to confirm these results." (Nascimento, F. O. et al. 2014)

This patient underwent successful elective and non-emergent stenting without complications and was monitored for an adequate post procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure, hemodynamic instability, cerebrovascular accident, severe bleeding, renal failure, need for urgent revascularization, need for prolonged intravenous medications, or oxygen support, or introduction of high-risk medications requiring prolonged in-hospital monitoring.

This setting, an inpatient level hospitalization, compared to an outpatient, has not been established as standard of care towards percutaneous catheterization or overall cardiac outcomes. It is therefore considered not medically necessary in this case.

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the inpatient emergency admission is upheld. Medical necessity is not substantiated.