Diagnosis: Coronary artery disease

Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission

The denial is upheld.

This patient has a history of hypertension and diabetes. He presented to the hospital for elective cardiac catheterization following a positive stress test. Prior to stress testing, the patient reported symptoms of dyspnea and lightheadedness. Cardiac catheterization revealed non obstructive disease of the left anterior descending and left circumflex arteries and severe disease in the right posterolateral coronary artery. A drug eluting stent was placed in right posterolateral artery. 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. He underwent an uncomplicated procedure and stents were placed in the right posterolateral artery. He was discharged the following 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 (Reference1-4). 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. The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.