Cardiac Heart Prob denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for Wegovy for weight loss.Obesity is a disease associated with a significant increase in mortality and many health risks, including type 2 diabetes mellitus, hypertension, dyslipidemia, and coronary heart disease. Weight loss in patients with obesity is associated with a reduction in mortality. The American Association of Clinical Endocrinologists (AACE) guidelines for the medical care of patients with obesity report that patients with obesity should be considered for treatment with weight-loss medication combined with lifestyle therapy when necessary.

A 64-year-old male enrollee has requested authorization and coverage for real-time remote heart monitoring for evaluation of the enrollee’s atrial fibrillation. Findings: Two physician reviewers found that the patient has a history of atrial fibrillation and atrial flutter. Per the patient, he has undergone electrical cardioversions previously as well as catheter ablation. He is being monitored for unclear reasons but presumably, given his extensive atrial tachyarrhythmias, for rhythm evaluation. His provider has recommended further monitoring with use of an ambulatory event monitor (also known as a memory loop recorder) with real-time capabilities, also known as auto-triggered memory loop recorders. The Health Plan has denied coverage stating that the requested device is considered investigational in the evaluation and treatment of this patient’s medical condition.

Where the denial was upheld

Physician 1: The patient is a 59-year-old male with coronary artery disease established by coronary angiography and treated with angioplasty in June of 2004. He has a recurrence of angina and a stress myocardial perfusion study in November 2005 was positive for ischemia in the anterior lateral left ventricle. The patient has declined coronary angiography. The treating physician has suggested cardiac CT angiography (CTA) as an alternative diagnostic procedure. The Health Plan has denied the request for CTA on the basis that the diagnostic procedure is experimental/investigational in this clinical context.There is not a scientific consensus that CTA is superior to conventional coronary angiography. As an additional consideration, if angioplasty is required for the treatment of a significant coronary artery stenosis, CTA will not provide an opportunity for intervention.

Physician 1: The patient is a 56-year-old woman who has a history of hyperlipidemia and smoking. She has been diagnosed with chest pain syndrome, she has “intermittent VEA” (ventricular ectopic activity) and she is treated with flecainide for “variable palpitations.” The specific arrhythmia that is being treated with flecainide was not described nor is the precise diagnosis associated with the palpitations. A stress test or perfusion study is not included in the documentation. The September 2006 provider’s note indicated the EKG was “NSR, NL” or normal. The provider also noted the patient did not have recurrent chest pain, but had intermittent VEA and chest pain with VEA. The provider indicated that CAD should be ruled out and referred the patient for CT angiography (CTA).

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 cardiac heart prob, then check the rights and deadlines that apply to your plan.