Diagnosis: Bilateral Claudication

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

This case involves a male with a past medical history of diabetes, chronic kidney (CKD) disease, anemia, hypertension, hyperlipidemia, and tobacco abuse. The patient had presented to the hospital with lower extremity pain upon exertion. He had undergone a staged peripheral angioplasty and drug-eluting stents were placed in the right external iliac. His medication regimen consisted of aspirin, Plavix, and atorvastatin and he was subsequently discharged home hemodynamically stable.

The requested hospital stay was previously denied and stated to be not medically necessary as it was stated that the patient could have been placed in observation under monitoring and that there was no evidence of hemodynamic, pulmonary, neurologic, or metabolic reasoning to treat him at an acute level of care.

The health care plan acted reasonably and with sound medical judgement in denial of the inpatient claim. This patient and his procedure could have safely been performed either as a completely outpatient procedure or observation.

There was no need for inpatient admission status.

The inpatient admission was not necessary for this patient.

The patient had bilateral lower extremity claudication. There was no documented rest pain or ulceration.

The patient presented for staged bilateral lower extremity endovascular intervention with the right side first. The patient's preoperative bloodwork was normal except for mild CKD. No EKG (electrocardiogram) changes, as they were normal sinus rhythm. The patient did not complain of other issues.

The patient underwent a routine aortogram, right lower extremity angiogram, right iliac PTA (Percutaneous transluminal angioplasty) and stent, and right SFA (superficial femoral artery) balloon angioplasty with endovascular lithotripsy. The patient had no complications intraoperatively or postoperatively.

Thus, there was no need for inpatient admissions. These types of cases are being done routinely throughout the United States as an outpatient procedure. If the time of day is late or the patient has some transportation issues, it is reasonable for observation, but there is absolutely no indication in this routine patient to have an inpatient admission.

Studies over the past decade have consistently shown that outpatient management of these peripheral Endovascular procedures is safe and is now the standard of care.

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

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