Cardiomyopathy denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that an enrollee has requested reimbursement for continued use of the Zoll LifeVest. The American Heart Association (AHA), American College of Cardiology (ACC), and Heart Rhythm Society (HRS) guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death (SCD) give the wearable cardioverter-defibrillator (WCD) a class IIb recommendation in patients at an increased risk of SCD but who are not eligible for an implantable cardioverter defibrillator (ICD), such as those awaiting cardiac transplant, having an left ventricular ejection fraction (LVEF) of less than 35% and are within 40 days from an myocardial infarction (MI), or have newly diagnosed nonischemic cardiomyopathy (NICM).

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for ZOLL® Wearable Cardioverter Defibrillator worn for three months. A reasonable and widely accepted timeframe for a repeat echocardiogram is four to six weeks after restoration of sinus rhythm to allow for reverse remodeling once the tachyarrhythmia is eliminated. If the left ventricular ejection fraction (LVEF) improves to greater than 35%, use of the LifeVest can usually be discontinued. If the LVEF remains less than or equal to 35%, continuation of the LifeVest and reevaluation at 90 days aligns with the guidelines on implantable cardioverter defibrillator candidacy.

Where the denial was upheld

Physician 1: The patient is a 50-year-old man who has cardiomyopathy (type unspecified). In addition, he has risk factors for coronary artery disease. The patient has a history of previous discordance between stress nuclear scanning and conventional coronary angiography. The patient’s provider has recommended an electron beam angiogram for further evaluation of the patient’s condition. The Health Plan denied the request on the basis that electron beam angiography is considered experimental. The Health Plan’s denial should be upheld. While electron beam angiography is a promising, non-invasive test for evaluating coronary anatomy, technical limitations make this test less sensitive than coronary angiography. Coronary angiography is the gold standard for detecting luminal narrowing.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued skilled nursing level of care including physical therapy and wound care. At issue is whether the requested continued skilled nursing level of care including physical therapy and wound care is medically necessary for treatment of this patient. Acute heart failure has multiple potential etiologies, but typically occurs in the setting of decompensation of a pre-existing cardiomyopathy (Abdo). Statins are generally safe and highly effective pharmacotherapeutic tools used in the management of dyslipidemia to reduce cardiovascular morbidity. Statin-induced myopathy is the most common cause for discontinuation of this therapy (Ward, et al.; Vinci, et al.).

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