Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease/CAD.
Treatment: Inpatient hospital stay.

The health plan denied the inpatient  hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient has a history of diabetes, chronic kidney disease, atrial arrhythmias, hypertension, hyperlipidemia, obstructive sleep apnea and obesity. He underwent myocardial perfusion imaging for symptoms of chest pain. This suggested an extensive area of ischemia. Cardiac catheterization showed significant disease in the left anterior descending coronary artery (LAD). No invasive intervention was performed at that setting given the patient's underlying renal disease. He was later admitted to the hospital for intravenous hydration prior to cardiac catheterization and planned percutaneous coronary intervention and for a consultation with a nephrologist. Upon admission the patient had no cardiac symptoms. His blood pressure was 185/80 millimeters of mercury (mmHg) with a heart rate of 54 beats/minute. His serum creatinine level was 2.46 milligrams per deciliter (mg/dl). His troponin I level was .03 nanograms/milliliter (ng/ml). There were no acute electrocardiographic changes. The next day his creatinine level was 2.66 mg/dl. The nephrologist recommended intravenous hydration for four hours pre-procedure and for 12 hours afterward. The cardiac catheterization was performed at which time a proximal LAD lesion was treated with rotational atherectomy and stenting; a mid-LAD lesion was stented. The procedure was uncomplicated. The patient's creatinine level was 2.13 mg/dl post-procedure. His troponin I level was 0.10 mg/dl. There were no electrocardiographic changes and the records provided do not indicate that he complained of chest pain. The next day the patient's creatinine level was 2.62 mg/dl. He was discharged.

Based on the documentation provided an inpatient level of care was not medically necessary.
This patient presented for scheduled cardiac catheterization and percutaneous coronary intervention (PCI). Given his chronic kidney disease, intravenous hydration pre-procedure was planned for prevention of contrast-induced nephropathy. Currently, there are no universally accepted methods for the prevention of contrast-induced nephropathy; however, for patients with an estimated glomerular filtration rate of less than 60 milliliters per minute (ml/min), intravenous hydration beginning six to 12 hours prior to the procedure and continuing for six to 12 hours after is a common approach. The nephrologist who consulted on this patient recommended intravenous saline for four hours prior to the procedure and for 12 hours afterward. This patient was admitted for hydration two days prior to the procedure. It is not clear from the records provided why a two-day period of hydration pre-procedure was deemed necessary nor is there support for this approach in the medical literature. Moreover, given this patient's stable clinical status, intravenous hydration would not have required an inpatient level of care.
The patient underwent rotational atherectomy in the proximal LAD and stent placement in the proximal and mid vessel. The procedure was uncomplicated. However, given the potential complications of coronary atherectomy, which may not be apparent at the time of the procedure, the 2018 expert consensus document from the Society for Cardiovascular Angiography and Interventions recommends overnight observation in the hospital. However, this does not require an inpatient level of care.
This patient developed a mild increase in his serum troponin level after PCI, without documented chest pain or electrocardiographic changes. This is a common occurrence, and no specific treatment was indicated. This did not warrant an inpatient admission.