Is continued inpatient level of care medically necessary for a patient with peripheral vascular disease (PVD) status post right common femoral artery focal endarterectomy and bypass surgery?

Continued Inpatient Stay is NOT Medically Necessary

Based on the clinical information provided, continued inpatient level of care on the requested date is not medically necessary for this patient who is postoperative day 1 following femoral-popliteal bypass surgery. The patient meets standard discharge criteria and should be discharged home with appropriate outpatient follow-up.

Clinical Status Assessment

The patient demonstrates all markers of uncomplicated postoperative recovery on postoperative day 1:

• Hemodynamically stable with vital signs stable (VSS) 1
• Adequate distal perfusion with warm right foot and palpable DP/PT signals, indicating no evidence of distal arterial insufficiency 1
• Functional mobility achieved, as patient ambulated in hallway with physical therapy 1
• Normal voiding function without urinary retention 1
• Intact surgical incision without bleeding or signs of infection 1
• No complications such as hypotension, bleeding, access-site problems, or neurological deficits 1

Guideline-Based Discharge Criteria

According to ACC/AHA guidelines for peripheral artery disease management, the immediate postprocedure period requires in-hospital monitoring for blood pressure control, prevention of bleeding and access-site complications, and neurological reassessment 1. This patient has successfully completed this monitoring phase without complications.

The standard expected length of stay for femoral-popliteal bypass is 1-2 days for uncomplicated cases 1. This patient is on postoperative day 1 and has met all discharge criteria:

• No hemodynamic instability requiring continued IV vasopressor support 1
• No bleeding complications requiring transfusion or reoperation 1
• Adequate pain control achievable with oral medications 1
• Ability to ambulate independently 1
• Appropriate discharge planning completed with patient education on incisional care 1

Postoperative Anticoagulation Management

The patient has been appropriately started on Xarelto 2.5 mg BID for peripheral artery disease, which is suitable for outpatient management 1. ACC/AHA guidelines recommend that all patients undergoing revascularization for critical limb ischemia should be placed on antiplatelet therapy and continued indefinitely 1. This medication can be safely administered in the outpatient setting without requiring continued hospitalization.

Required Outpatient Follow-Up

Rather than continued inpatient stay, this patient requires structured outpatient surveillance per ACC/AHA guidelines 1:

• Early postoperative visit within 1 week to assess wound healing and distal perfusion 1
• Duplex ultrasound surveillance at 1,3,6,12,18, and 24 months postoperatively for autogenous vein grafts (or at 1,6,12, and 24 months for prosthetic grafts) 1
• Serial ABI measurements and pulse examinations to detect graft stenosis or failure 1
• Cardiovascular risk modification including smoking cessation, lipid control, blood pressure management, and diabetes control 1, 2, 3

Common Pitfalls to Avoid

The absence of progress notes for the continued stay date does not justify automatic approval of additional inpatient days. The clinical information provided demonstrates:

• No acute complications requiring inpatient-level monitoring 1
• No critical limb ischemia with threatened limb loss requiring intensive intervention 1
• No hemodynamic instability requiring IV medications 1
• No wound complications requiring inpatient wound care 1

Continued hospitalization beyond postoperative day 1 in this stable patient would not improve clinical outcomes and represents unnecessary healthcare utilization 1.

Recommendation

Discharge home on the requested date with:

• Continuation of Xarelto 2.5 mg BID 1
• Outpatient vascular surgery follow-up within 1 week 1
• Instructions for incisional care and signs/symptoms requiring urgent evaluation 1
• Comprehensive cardiovascular risk modification program 1, 3
• Scheduled duplex surveillance per protocol 1