Diagnosis: Stenosis of the right coronary artery (RCA) and the left anterior descending (LAD)

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient has a history of coronary artery disease, diabetes, peripheral polyneuropathy, and hyperlipidemia. He complained of chest pain. Echocardiogram showed 30-35% (percent) ejection fraction. He underwent diagnostic cardiac catheterization and was found to have a high-grade stenosis of the right coronary artery (RCA) and the left anterior descending (LAD) artery. He had a drug eluting stent implanted to the RCA. The patient presented to the hospital for an elective staged cardiac catheterization with percutaneous coronary intervention (PCI) to the LAD artery. A drug eluting stent to the LAD was implanted successfully. The patient was admitted and observed and monitored uneventfully overnight and discharged.

The patient had an elective coronary intervention. It was reasonable to observe the patient for several hours after intervention to assure clinical stability and no adverse cardiac outcomes or bleeding. A full admission was not necessary.

A short period of observation to assure no acute complications such as bleeding was appropriate, but that could have been performed on observation status.

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