Diagnosis: Palpitations.
Treatment: Inpatient Stay.

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

The patient is a male with history of hypertension, hyperlipidemia, coronary disease, and diabetes. The patient was admitted for palpitations and dyspnea in the setting of heavy lifting. Troponins were minimally elevated in the setting of a hypertensive emergency with a systolic blood pressure (BP) over 200. An Echocardiography demonstrated a normal left ventricular ejection fraction (LVEF). A computed tomography (CT) angiography demonstrated non-obstructive coronary disease. There was an abnormal FFR (fractional flow reserve) in the left anterior descending (LAD) and left circumflex. He underwent atherectomy and stenting of the LAD and circumflex. There were no complications. His BP was reported as well-controlled. His heart rate was in the normal range. On admission, he was on amlodipine, aspirin, and a statin. He was also on an ace inhibitor and metformin.

The inpatient hospital admission was not medically necessary.

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 has not been established as the standard of care towards percutaneous catheterization or overall cardiac outcomes. It is therefore considered not medically necessary in this case. The patient could have been cared for at a lower level of care.