Dilated Cardiomyopathy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for wearable cardioverter defibrillator for treatment of the enrollee’s dilated cardiomyopathy. Findings: The 3 physician reviewers found that the physician reviewers found the documented high risk of sudden cardiac death in patients with severe left ventricular dysfunction has led to the recommendation of implantable cardioverter defibrillators in this group of patients. Current data from multiple trials and registries have advocated the use of a wearable cardioverter defibrillator after an initial diagnosis of severe left ventricular dysfunction. In this patient’s case, the records documented an ejection fraction of 35 to 40%. Given the absence of significant coronary artery obstructive disease, this was considered a non-ischemic cardiomyopathy.

A 65-year-old male enrollee has requested a wearable cardioverter defibrillator (LifeVest treatment) for treatment of his dilated cardiomyopathy. Findings: Two physician reviewers found the wearable cardioverter defibrillator (LifeVest treatment) was likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. An increase in the risk of sudden cardiac death (SCD), and a potential benefit from implantable cardioverter defibrillator (ICD) implantation, has long been recognized in patients with left ventricular dysfunction related to underlying ischemic heart disease. An increase in SCD risk and potential benefit from an ICD has also been demonstrated in patients with a nonischemic cardiomyopathy.

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 durable medical equipment for treatment of the enrollee’s dilated cardiomyopathy. Findings: 2/3 of the physician reviewers found that based on the records provided the patient is a 65-year-old male who presented with heart failure and coronary ischemia treated with coronary bypass and left ventricular aneurysmectomy with a post-operative left ventricular ejection fraction of 25-30%. In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy and there was no documented indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest.

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