Ischemic Cardiomyopathy: when insurers say no, reviewers often say yes

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a Zoll LifeVest. The researchers’ guidelines note that patients with recent myocardial infarction, newly diagnosed nonischemic cardiomyopathy, recent revascularization, myocarditis, and secondary cardiomyopathy are at increased risk of sudden cardiac arrest. Patients who may benefit from automatic emergency cardioversion-defibrillation but do not meet indications for implantable cardioverter-defibrillator (ICD) implantation at the time of presentation include those who are at perceived increased risk of sudden cardiac death due to severe left ventricle dysfunction but for whom there may be optimism for clinical improvement, and those who have a clear indication for ICD but who have a contraindication to immediate placement.

Nature of Statutory Criteria/Case Summary: A 50-year-old female enrollee has requested reimbursement for the Zoll LifeVest wearable cardioverter defibrillator.The American College of Cardiology (ACC) and American Heart Association (AHA) guidelines note that patients with recent myocardial infarction, newly diagnosed nonischemic cardiomyopathy, recent revascularization, myocarditis, and secondary cardiomyopathy are at increased risk of sudden cardiac arrest. Patients who may benefit from automatic emergency cardioversion-defibrillation but do not meet indications for ICD implantation at the time of presentation include those who are at perceived increased risk of sudden cardiac death due to severe left ventricle dysfunction but for whom there may be optimism for clinical improvement, and those who have a clear indication for ICD but who have a contraindication to immediate placement.

Where the denial was upheld

Physician 1: The patient is a 47-year-old male with ischemic cardiomyopathy. He has an ejection fraction (EF) of 35% and is status post Automatic Implanted Cardiac Defibrillator (AICD) placement. He is reportedly on “optimal therapy for heart failure” and underwent bioimpedance testing for assessment of his fluid status in April, 2005. The patient now requests reimbursement for the diagnostic procedure. The Health Plan considers bioimpedance testing experimental/investigational and has denied coverage.The following is an excerpt from the most recent American College of Cardiology/ American Heart Association Practice Guidelines for heart failure (HF):There has been no established role for periodic invasive or noninvasive hemodynamic measurements in the management of HF.

Physician 1: This patient is a 57-year-old male who has known ischemic cardiomyopathy and is at risk for a stroke with paroxysmal atrial fibrillation. He has several comorbid conditions and standard treatment with Coumadin is thought to be risky because of unexplained GI bleeding. The patient’s provider has recommended the patient undergo implantation of a left atrial appendage occluder device known as PLAATO. The Health Plan has denied the request on the basis the requested device is considered investigational.Implantation of the PLAATO device is a very new technique that is currently under study to help prevent strokes in certain patients. It was only first described in the canine model in 2002 and hence, there is no real long-term data available. The largest study of PLAATO published thus far involved 111 patients (Ostermayer, et al.).

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for ischemic cardiomyopathy was denied, the published record says the denial is worth fighting.