Atrial Fibrillation denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a LifeVest wearable cardiovascular defibrillator for treatment of the enrollee’s medical condition. Findings: Two physician reviewers found that the patient was presented with three week history of increasing dyspnea on exertion progressing to dyspnea at rest, orthopnea and paroxysmal nocturnal dyspnea. He presented with a new onset atrial fibrillation with rapid ventricular response. The patient underwent transthoracic echocardiogram and transesophageal echo (TEE) which revealed moderately severe global left ventricular (LV) dysfunction, moderately severe mitral insufficiency and left atrial appendage thrombus. The patient also underwent cardiac nuclear study which did not show active ischemia.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a surgical endoscopic heart procedure (CPT 33266 - operative tissue ablation and extensive reconstruction of atria without cardiopulmonary bypass).Findings: Two of the three physician reviewers found the requested surgical endoscopic heart procedure (CPT 33266 - operative tissue ablation and extensive reconstruction of atria without cardiopulmonary bypass) is likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. A hybrid procedure of minimally invasive surgery and combined electrophysiology (EP) mapping and ablation for atrial fibrillation may overcome the shortcomings of each technique individually.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for skilled nursing facility services from 5/15/21 through 5/22/21.The patient has had recurrent strokes deemed to be cardioembolic in nature, in the setting of chronic atrial fibrillation with high CHADS-VASC score. Each stroke was treated within a short timeframe, with rapid to early restoration of arterial flow, minimizing the extent of damage to the neuronal reservoir, which is the primary determinant of outcomes following stroke according to Alawieh and colleagues. By 5/14/21, the patient had 5-/5 strength on the left side and some mild functional deficits that could be further addressed with rehabilitation in the community setting. Continued stay in a skilled nursing facility in case he had another stroke was not a medical necessity.

The patient is a 56-year-old male who has requested authorization for a virtual colonoscopy for colon cancer screening. The patient has been on Coumadin for recurrent atrial fibrillation and he is concerned that discontinuing his anticoagulation therapy prior to a standard colonoscopy will put him at risk. Therefore, he is seeking approval of a virtual colonoscopy. The Health Plan has denied his request on the basis that a virtual colonoscopy is not medically necessary.Virtual colonoscopy represents a noninvasive test for the examination of the colonic lumen that involves the generation of both two-dimensional and three-dimensional views of the colon and rectum using data derived from computed tomography. This imaging modality has been explored as an alternative to conventional endoscopic colonoscopy, particularly as an alternative screening tool for colorectal cancer.

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 atrial fibrillation, then check the rights and deadlines that apply to your plan.