Diagnosis: Ischemic heart disease.
Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.

This patient has a history of ischemic heart disease, hypertension, and diabetes that presented to the hospital for elective cardiac catheterization as part of a staged revascularization. Drug eluting stents were placed in both vessels. No perioperative complications were noted, and the patient was discharged the following day.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient. This patient presented for elective percutaneous revascularization via radial artery approach. He underwent an uncomplicated procedure and drug eluting stents were placed in the mid LAD [left anterior descending] artery. The procedure was uncomplicated, and the patient was discharged later that same day. Several investigators have studied the safety and cost savings surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital (Reference 1-4). Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care (Reference 4). In conclusion, inpatient admission was not medically necessary. The patient could have been managed at a lower level of care.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.