Diagnosis: Elective cardiac catheterization
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

This patient is an adult male for whom an inpatient hospitalization is under review. There was a history of hypertension and a cerebrovascular accident. There was shortness of breath that was worse when lifting heavy boxes. There was no chest pain. He was unable to attempt a treadmill test due to back pain. Echocardiography revealed an ejection fraction of 30-35%. A position emission tomography/computed tomography scan demonstrated an ejection fraction of 20% in a small area of mild inferior and inferior-lateral ischemia. The patient presented for an elective cardiac catheterization. Vital signs were essentially normal. The electrocardiogram was normal. Cardiomyopathy medical therapy was initiated. The patient underwent a successful percutaneous intervention of the circumflex. He remained stable and was discharged.

The proposed treatment is not medically necessary.

This patient presented electively for a heart catheterization in the setting of a cardiomyopathy. There was no congestive heart failure, respiratory distress, ongoing symptoms suggestive of treatment refractory angina or angina equivalent, severe arrhythmia, hemodynamic instability, need for prolonged intravenous medications or oxygen support, introduction of high-risk medications requiring ongoing in-hospital monitoring, severe catheterization related complication (i.e., severe bleeding, cerebrovascular accident), need for invasive hemodynamic monitoring, need for vasopressor or mechanical cardiac support, or supporting evidence for an acute coronary syndrome such as elevated cardiac biomarkers or an abnormal electrocardiogram.
In the setting of this case, an acute inpatient level hospitalization, compared to for example outpatient, has not been established as standard of care toward improved cardiac outcomes. It is, therefore, considered not medically necessary in this case.