Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The determination is upheld.

This is a male patient with chest pain and an abnormal outpatient stress test. He underwent a cardiac catheterization and stenting of left anterior descending (LAD) and diagonal bifurcation stenosis. The creatinine was normal. There were no complications and he remained stable. At issue is the medical necessity of an inpatient stay.

This patient underwent successful elective and non-emergent stenting without complications and was monitored for an adequate post procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, renal failure, need for urgent revascularization, need for prolonged intravenous medications or oxygen support, or introduction of high-risk medications requiring prolonged in-hospital monitoring. In this setting, an inpatient level hospitalization, compared to for example outpatient, has not been established as standard of care toward percutaneous catheterization or overall cardiac outcomes. It is therefore not considered medically necessary in this case.