Heart Disease 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 a heart surgery, a patent foramen ovale (PFO) closure (using a Cardioform percutaneous device). Nietlispach and Meier advocate for the use of percutaneous PFO closure for primary stroke prevention in high-risk populations, which includes patients who are suffering from a disease associated with PFO. In a review of patient-pooled analysis, Desai and colleagues found that PFO closure for the treatment of migraine, both with and without aura, was safe and reduced the average number of monthly migraine days and attacks compared with medical therapy.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with coronary artery disease (CAD). The patient reported occasional chest tightness and a vague aching sensation that occurred with exercise and rest. The patient was treated with a two-vessel coronary artery bypass graft (CABG). The provider noted nuclear stress testing and a stress echocardiogram were negative for ischemia. The patient has requested reimbursement for coronary computerized tomography angiography that was provided. The Health Plan denied the request and reported that the services at issue were not medically necessary for the evaluation of this patient. At issue in this case is whether coronary computerized tomography angiography was medically necessary for the evaluation of the patient’s medical condition.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a computed tomographic angiography (CTA) of coronary arteries. This patient is asymptomatic without clinical evidence of myocardial ischemia, with freedom from anginal-type chest pain or exertional dyspnea. Cardiovascular testing undergone by the patient, including resting echocardiogram and serial electrocardiograms, has also been without ischemic findings. Furthermore, no evidence of atherosclerotic cardiovascular disease (ASCVD) is evident, with normal carotid duplex imaging and a prior coronary artery calcium (CAC) score of 0. Other markers of elevated ASCVD, such as diabetes mellitus and tobacco use, are similarly absent.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for patent foramen ovale (PFO) percutaneous transcatheter closure of congenital interatrial communication with implant. Researchers note that the two accepted indications for PFO closure are paradoxical embolization or hypoxia. Researchers report, “The presence of a PFO in patients undergoing liver transplantation is not associated with postoperative cerebral vascular accident. Prophylactic closure of PFOs, in the absence of other indications, does not appear to be warranted in patients undergoing liver transplantation.” In this case, while the records show that the patient has PFO, there is no history of paradoxical embolization or hypoxia.

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