Congestive Heart Failure 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 reimbursement for LifeVest Wearable Cardioverter Defibrillator (WCD) billed by Zoll Services. This patient presented with newly diagnosed congestive heart failure. The patient was referred for a LifeVest WCD. The provider noted that the patient did not complete three months of guideline directed medical therapy and had an estimated high risk of sudden cardiac death that had the potential to progress over time. Per the current American Heart Association (AHA) guidelines, the use of a WCD for primary prevention of sudden cardiac death is appropriate in patients with non-ischemic cardiomyopathy with left ventricle ejection fraction (LVEF) of 30% or less, on chronic optimal medical therapy.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a wearable cardiovascular defibrillator (Zoll LifeVest) provided Findings: The physician reviewer found that The patient is a patient with a history of smoking, obstructive pulmonary disease and diabetes. The patient presented with dyspnea symptoms due to congestive heart failure. The patient was evaluated with severely depressed left ventricular ejection fraction and subsequent cardiac catheterization. The report noted normal coronary arteries without stenosis. The patient was medically managed and discharged with a wearable defibrillator. A follow up visit reported fatigue and exertional dyspnea. An echocardiogram later reported a left ventricular ejection fraction of 15%. An implantable defibrillator was placed .

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage to remain in a skilled nursing facility and continue physical therapy for treatment of the enrollee, who has a history of congestive heart failure. Findings: The physician reviewer found that This patient has a history of dilated cardiomyopathy with an ejection fraction of 20-25% and New York Heart Association (NYHA) class III-IV congestive heart failure. He has had multiple episodes of volume overload in the last year requiring intensive diuresis. He was hospitalized with volume overload and pneumonia. He was aggressively treated in the hospital over a week and medically stabilized. He has been receiving care at the skilled nursing facility, primarily for deconditioning. He had made very modest functional progress.

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 congestive heart failure, then check the rights and deadlines that apply to your plan.