Diagnosis: Coronary Artery Disease (CAD).
Treatment: Inpatient Hospital.
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.


This female patient presented to the hospital for scheduled intra-coronary brachytherapy for a 95% in-stent restenosis in her mid-left anterior descending coronary artery. Her medical history was remarkable for hypertension, hyperlipidemia, type 2 diabetes with neuropathy and chronic foot ulcers, and cigarette smoking. The brachytherapy was followed by balloon angioplasty; the procedure was uncomplicated. The patient was admitted to the hospital post-procedure and remained stable overnight. She was evaluated by a vascular surgeon and the wound care team for a necrotic lesion on her right third toe with mild erythema on her lower leg. She was then discharged.
At issue is the medical necessity of the inpatient hospital admission.
The health plan's determination of medical necessity is upheld in whole.
Based on the documentation provided an inpatient level of care was not medically necessary.
While some period of observation immediately following percutaneous coronary intervention (PCI) is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. The 2009 Expert Consensus Document from the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, 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 met none of these criteria. Per the 2018 update to this document, with the exception of patients with ST segment elevation myocardial infarction, most stable patients can be discharged post-PCI on the day of the procedure, provided they are at their baseline functional and mental status and all of their baseline comorbidities are stable.