Hypertrophic Cardiomyopathy denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 57-year-old male with hypertrophic cardiomyopathy and dyslipidemia. He is status post pulmonary vein isolation for atrial fibrillation. He underwent a computed tomography angiography (CTA) in May 2006 to exclude pulmonary vein stenosis. Calcium scoring was also performed to help decide on long-term statin therapy. The Health Plan has denied reimbursement for the CTA on the basis that it is considered investigational.Traditional diagnostic modalities (e.g., CT scanning) are not sufficient to adequately detect pulmonary venous stenosis post ablation. In such cases, CTA is clinically superior and appropriate. Although large, multicenter studies of CTA are still pending, there is adequate evidence of its efficacy to support its use for patients such as this patient.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cardiac defibrillator implantation for treatment of the enrollee’s hypertrophic cardiomyopathy. Findings: The 3 physician reviewers found that this patient presents with a history of hypertrophic cardiomyopathy and symptomatic non-sustained ventricular tachycardia. In this circumstance, accepted criteria for prophylactic defibrillator placement include the presence of at least two clinical risk factors. These factors include unexplained syncope, non-sustained ventricular tachycardia, family history of sudden death in a first degree relative, abnormal blood pressure response to exercise and left ventricular wall thickness greater than 30 mm.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for a wearable cardioverter defibrillator (Zoll LifeVest) or treatment of the enrollee who has a history of hypertrophic cardiomyopathy. Findings: The physician reviewer found that The benefits of the wearable cardiac defibrillator (WCD) have been the subject of intensive study. Moreover, WCD has not been a proven benefit for newly diagnosed patients with cardiomyopathy. Guidelines of the Heart Rhythm Society (HRS) and the American College of Cardiology (ACC) do not support use of the WCD. Instead, the guidelines recommend permanent ICD after a waiting period of 45 to 90 days if potentially reversible causes are present but the WCD has not been proven beneficial in this situation. There is a lack of randomized trial, which have shown the benefits of WCD over and above that of optimized medical therapy.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for subcutaneous implantable cardioverter defibrillator (ICD). Based on the records provided for review, the patient has hypertrophic cardiomyopathy. The patient’s records document an increased risk of sudden death as evidenced by sudden death in his brother and non-sustained ventricular tachycardia (NSVT). In this circumstance, placement of a cardioverter defibrillator is appropriate. However, there is no documented contraindication to a standard implantable cardioverter defibrillator using a transvenous ventricular lead. In addition, optimal patient selection criteria and long-term complications with a subcutaneous leadless defibrillator have not been established.

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