Cardiac Valve Dis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter aortic valve replacement with prosthetic valve, percutaneous femoral artery approach.Findings: Two out of three physician reviewers found that the medical evidence supports the requested services in this clinical setting. The medical records demonstrate that the patient has symptomatic aortic stenosis, based on recent onset symptoms of dyspnea with limited (1 block or incline) exertion, fatigue and dizziness, and she therefore has Class II heart failure symptoms. The patient had a recent transthoracic echocardiogram (TTE) which revealed moderately severe to severe aortic stenosis secondary to a bicuspid valve.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter closure of a patent foramen ovale (PFO) using a cardiac occlusion device. As noted in the medical literature, PFO can be a benign finding, but in some patients, the PFO can be associated with stroke and systemic embolization. Percutaneous closure of the PFO in patients with cryptogenic stroke has been undertaken for a number of years. Recent randomized controlled clinical trials have demonstrated that closure of PFO in patients with cryptogenic stroke has been associated with reduced rates of recurrent stroke.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a heart monitor. In this case, if cardiac monitoring were thought to be indicated to evaluate for palpitations, then non-real time (off-line) monitoring devices such as extended (48 hour) Holter monitoring or off-line event monitoring should be sufficient for the identification of both symptomatic and asymptomatic dysrhythmias including atrial fibrillation. Continuous off-line 24-to-48 hour Holter monitoring should be able to effectively identify symptomatic or asymptomatic dysrhythmias that occur frequently. Likewise, self-activated non-real time and non-continuous monitoring devices (event recorders) should be effective at recording symptomatic dysrhythmias during less frequent symptoms.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter mitral valve replacement. There is a lack of formal guidelines or consensus statements available to support treatment with transcatheter mitral valve-in-valve replacement for treatment of this patient’s bioprosthetic mitral valve failure. Urena and colleagues noted that patients may be eligible for transcatheter mitral valve-in-valve replacement if “they are symptomatic, they are considered at high surgical risk, and their anatomy is suitable.” However, the available clinical trials comparing transcatheter mitral valve-in-valve replacement and surgical mitral valve replacement have not reported superior health outcomes with transcatheter approach. The U.S.

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 valve dis, then check the rights and deadlines that apply to your plan.