Arrhythmia denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the Zoll life vest-Wearable Cardioverter Defibrillator. According to the literature, wearable cardioverter defibrillators protect individuals at high risk for sudden cardiac complications. In this case, the patient has a high risk for sudden cardiac complications due to a low left ventricular ejection fraction and a history of arrhythmia. Therefore, the Zoll life vest-wearable cardioverter defibrillator was likely to have been more beneficial for the treatment of the patient’s arrhythmia than any available standard therapy.

A 20-year-old female enrollee has requested the use of a real time remote heart monitor (electrocardiographic monitor) for an evaluation of her heart condition. Findings: Two physician reviewers found that this patient clearly had symptoms that could not be confined to a 24-hour period and other options, such as obtaining an electrocardiogram during the episode, were not practicable. The only means to establish the presence of an arrhythmia was by the use of the real-time remote heart monitor (electrocardiographic monitor) during the symptoms. There is every clinical indication to use an event recorder such as this which can be triggered by the patient during her episodes. This would, undoubtedly, help, not hinder in looking after this patient. Thus, the use of a real-time remote heart monitor was appropriate and indicated.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acute inpatient rehabilitation services. Findings: The physician reviewer found that (AAPMR) has outline specific criteria for a patient to qualify for acute inpatient admission. Per the AAPMR recommendations, a patient’s records should document that the patient has significant functional deficits and medical and nursing needs that require close medical supervision by a physician, 24-hour availability of nurses skilled in rehabilitation, and treatment by multiple other licensed rehabilitation professionals in a time intensive and medically coordinated program.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for mobile cardiac outpatient telemetry (MCOT). Ambulatory cardiac monitoring is recommended for patients with a suspected arrhythmia. The type and duration of monitoring are based on a patient’s history and frequency of symptoms. A Holter monitor is recommended if symptoms occur several times a week. If the frequency is every one to two weeks, an external event recorder is recommended. If the frequency is less than once every two weeks, an implantable event recorder is recommended. Given this patient’s clinical history of coronary artery disease, syncope, and limited cardiac risk factors, ambulatory event monitoring was indicated. There is insufficient documentation to support the need for real-time monitoring in the absence of high-risk features or risk factors.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving arrhythmia, then check the rights and deadlines that apply to your plan.