Diagnosis: Cardiac/Circulatory Problems.
Treatment: Inpatient Hospital.

The insurer denied Inpatient Stay.
The denial is upheld.

The patient is a male, who presented to the hospital for scheduled cardiac catheterization for complaints of exertional chest pain. His medical history was remarkable for diabetes. His coronary artery calcium score was 1171; coronary computed tomography (CT) angiography suggested a hemodynamically significant stenosis in the left anterior descending coronary artery (LAD). Coronary angiography showed significant proximal and mid-LAD stenosis. The right coronary artery was diffusely diseased. Two drug-eluting stents were implanted in the LAD. The procedure was uncomplicated. Post-procedure the patient was admitted to the hospital. He remained stable overnight and was discharged the following day.

At issue is the Inpatient Stay for medical necessity.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Inpatient Stay was not medically necessary for this patient.
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. Current guidelines from the Society for Cardiovascular Angiography and Interventions recommend inpatient admission in patients with acute ST segment elevation 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 had stents placed in the same vessel and his procedures were uncomplicated and did not require an inpatient level of care.
Therefore, the requested health service/treatment of Inpatient Stay was not medically necessary.