CHF denials in California external review

What the reviewers wrote

Where the denial was overturned

A 53-year-old male enrollee requested authorization and coverage of external counterpulsation therapy. The Health Plan denied the request indicating that the requested therapy is experimental for treatment of the enrollee’s congestive heart failure.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy.

A 58-year-old female enrollee requested the wearable cardioverter defibrillator for medical treatment of her congestive heart failure. Findings: The physician reviewer found that given this patient’s presentation with severe cardiomyopathy and recurrent episodes of sustained ventricular tachycardia, it was reasonable to place the wearable cardioverter defibrillator while awaiting the recovery of the heart function. The efficacy of the wearable cardioverter defibrillator has been tested for induced ventricular tachyarrhythmias as well as for spontaneous events in clinical trials and post-market study. Consistent with these findings, the wearable cardioverter defibrillator was medically necessary for treatment of this patient’s medical condition.

Where the denial was upheld

Physician 1: The patient is a 54-year-old male who has requested authorization and coverage for a home defibrillator kit. Review of the submitted medical documentation indicates the patient has a history of dilated cardiomyopathy. His most recent echocardiogram demonstrated left ventricular enlargement, moderate to severe, with global hypokinesis and an estimated ejection fraction of 20-25%. The patient’s physician has recommended the patient undergo implantation of an automatic internal cardioverter defibrillator (AICD). The patient wishes to receive a home defibrillator kit. The Health Plan has denied this request indicating that the requested device is considered investigational for treatment of the patient’s condition. The Health Plan’s denial should be upheld. The provided documentation indicates the patient has not had a recent cardiology evaluation.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Zoll LifeVest (K0606). The Health Plan has denied this request indicating that the equipment at issue was not medically necessary for treatment of the enrollee who has a history of congestive heart failure. Findings: Current medical literature does not support the equipment at issue in this clinical setting. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or require explantation. Based on the records provided, the patient had a newly recognized cardiomyopathy with an ejection fraction of 20-25% that subsequently improved on repeat echocardiograms.

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