Diagnosis: Chest Pain; s/p Cardiac Catheterization with Percutaneous Cardiac Intervention.
Treatment: Inpatient Stay.

The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a male, who has a history of hypertension, hyperlipidemia, diabetes, chronic obstructive pulmonary disease (COPD), morbid obesity, a non-segment (ST) elevation myocardial infarction with multivessel coronary artery disease (CAD) diagnosed at that time. He was admitted electively for percutaneous intervention of the left anterior descending (LAD) and circumflex. The left ventricular ejection fraction (LVEF) was normal. The patient's creatinine was normal. The electrocardiogram (ECG) was not acute. His vital signs were normal. He underwent a successful percutaneous intervention. He remained stable and was discharged.

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

The requested health service/treatment of an inpatient stay was not medically necessary for the patient. This patient presented for an elective percutaneous intervention. He remained stable. There was no congestive heart failure (CHF), respiratory distress, ongoing symptoms suggestive of treatment refractory angina or angina equivalent, severe arrhythmia, hemodynamic instability, other serious cause for chest pain, such as a pulmonary embolism (PE) or the need for an aortic dissection. The patient did not need prolonged intravenous (IV) medications or oxygen support, introduction of high risk medications requiring ongoing in-hospital monitoring, he did not have a severe catheterization related complication (i.e., severe bleeding, cerebrovascular accident (CVA)), need for invasive hemodynamic monitoring or the need for vasopressor or mechanical cardiac support. The patient did not have supporting evidence for an acute coronary syndrome such as elevated cardiac biomarkers or an abnormal ECG. In the setting of this case an acute inpatient level hospitalization, compared to for example an alternate level of care, has not been established as standard of care towards improved cardiac outcomes. It is therefore considered not medically necessary in this case.
The health plan's determination of medical necessity is upheld in whole.