Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems - Coronary Artery Disease / CAD
Inpatient Hospital

The patient is a male with a history of hypertension, dyslipidemia, coronary artery disease with history of (h/o) coronary artery bypass graft (CABG), who was seen as an outpatient by the cardiologist.  Per chart review, the patient reported a 6 week history of worsening typical angina with activities such as walking 3-4 blocks or walking up 1 or more flights of stairs.  His cardiologist recommended a cardiac catheterization with possible percutaneous coronary intervention (PCI) to evaluate the origin of the patient's angina.

The patient presented to the hospital for cardiac catheterization.  This test revealed multi-vessel, obstructive coronary artery disease (CAD).  It also revealed occluded saphenous vein graft (SVG) to diagonal 2 branch of left anterior descending (LAD), patent left internal mammary artery (LIMA) to LAD, patent right internal mammary artery (RIMA) to right marginal branch of right coronary artery (RCA), and 99% ostial stenosis of radial artery graft to the ramus intermedius artery.  This 99% stenosis was treated with placement of a Synergy drug-eluting stent (DES) 2.5 millimeter (mm) x 8 mm.  The patient was loaded with acetylsalicylic acid (ASA) and Effient and was started on intravenous (IV) Aggrastat after the procedure.  The patient tolerated the procedure well and was kept overnight in the hospital.  The patient was stable overnight and was discharged to home the next day.

The health plan's determination is upheld.

Although overnight monitoring of patients in the hospital after coronary artery or bypass graft angioplasty or stenting is considered the standard of care in the United States, in this case the patient could have been treated at a lower level of care and did not require an inpatient hospital stay.

It is standard of care to hospitalize patients overnight (ON) after a PCI procedure with the goal of hospital discharge the next day.  The patient in this case review underwent a successful PCI procedure and was discharged from the hospital the next day.

At most hospitals in the United States, same day discharge (SDD) is not considered the standard of care after uncomplicated PCI procedures.

A meta-analysis regarding overnight (ON) vs. same day discharge (SDD) after uncomplicated PCI from Journal of the American College of Cardiology (JACC): Interventions addressed this topic.  In that article, the authors state "our comprehensive review involved a total of 111,830 patients (2,039 enrolled in randomized trials, and 109,791 in observational studies), with 4,179 (3.7%) in the same day discharge (SDD), and 107,651 (96.3%) in the ON group." 1

From this same review article, the authors conclude that there is not yet enough data in clinical trials in order to adopt SDD as the standard of care after uncomplicated PCI in the United States.  They stated that "due to the low event rate, the significant variation in the definition of outcomes across studies, and wide confidence intervals around the pooled point estimates, a definitive resolution of a statistically significant hazard or benefit to the SDD approach cannot be determined based on the totality of presently available data." 1

In addition, since this patient was given IV Aggrastat post-PCI, the interventional cardiologist likely thought that there was a high risk for stent thrombosis in this anatomic location for this patient.  According to UpToDate, "for patients who by angiographic criteria are at high risk for a stent thrombosis, we suggest the addition of glycoprotein (GP) IIb/IIIa inhibitor therapy (Grade 2C)." 2  Since this patient's stent was likely considered at risk for thrombosis, he would not have been an ideal candidate for same day discharge.  However, he could have been managed at a lower level of care status, and an inpatient stay was not medically necessary.