Diagnosis: Cardiac/Circulatory Problems/Angina
Treatment: Surgical Services (All)
The health plan denied the requested inpatient stay as not medically necessary.
The health plan's determination is upheld.

The patient is a woman with a past medical history of hypertension, hyperlipidemia, diabetes, obesity, osteoarthritis and worsening spinal stenosis. For the evaluation of exertional dyspnea, she had a coronary angiography which demonstrated occlusive lesions in the proximal left anterior descending (LAD) and distal right coronary artery (RCA). She was offered a coronary artery bypass graft (CABG) but instead opted for multivessel percutaneous coronary intervention (PCI). Consequently, she presented for a staged PCI. This was performed and she had placement of drug eluting stents to her LAD and left circumflex artery and medical management of her RCA lesion was recommended. She was started on dual antiplatelet therapy with aspirin and Plavix and was admitted to the telemetry unit overnight. She did not have any events overnight and was discharged home the next day.
At issue is the medical necessity of the inpatient stay.

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

This patient presented for an elective outpatient PCI. Her proximal LAD and left circumflex artery were treated with drug eluting stents. There were no intraprocedural complications such as significant bleeding, coronary dissection, or perforation. There was also no evidence of access/vascular complications. She was hemodynamically and electrically stable during the procedure and post-procedurally. She did not have evidence of acute coronary syndrome, there was no heart failure, no renal failure, no need for therapeutic anticoagulation and no antiplatelet or contrast allergy. She did not have any chest pain post-procedurally. Consequently, based on the provided documentation, there is insufficient clinical data to support the medical necessity for an inpatient level of care. Observation level of care would have been appropriate in this case.