Diagnosis: Coronary Artery Disease
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This patient reported a history of chest pain and dyspnea on exertion and presented to the hospital for elective cardiac catheterization. Past medical history was significant for hypertension, transient ischemic attack (TIA), seizure disorder and colon cancer. Cardiac catheterization was performed and revealed severe triple vessel coronary artery disease. The patient was prescribed guideline directed medical therapy and referred for cardiothoracic surgical consultation. There were no perioperative complications. He was discharged on the day of presentation.

Several investigators have studied the safety 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 hospital. (Reference1-4) Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care (Reference 4).

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.