Myocardial Infarction denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: enrollee has requested reimbursement for the wearable cardioverter defibrillator (WCD) for evaluation of the enrollee’s diabetes, hypertension, and non ST elevation myocardial infarction (STEMI). Findings: The physician reviewer found that current data from multiple trials and registries have advocated the use of a WCD after an initial diagnosis of severe left ventricular dysfunction as demonstrated by an ejection fraction less than 35%. This patient’s ejection fraction was estimated at 15%. The American College of Cardiology (ACC) and American Heart Association (AHA) recommend against placing an implantable cardioverter defibrillator within three months of the initial diagnosis of heart failure, within 40 days of myocardial infarction, or within three months of coronary revascularization.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) level of care until the enrollee has open heart surgery. In this case, while the records do not document the patient’s disabilities in terms of patient’s ability to live independently or the degree of home support needed, the degree of right hemiparesis, possible dysphagia, visual acuity, exercise tolerance in general, ability to communicate and to manage medical conditions including diabetes preclude a safe discharge into the community. The records note that the patient lives alone and receives disability benefits, indicating that the patient has been disabled for a length of time.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a wearable cardioverter defibrillator for three months. The wearable cardioverter defibrillator is indicated as a temporary therapy for patients with a high risk for sudden cardiac death (SCD). The American College of Cardiology (ACC), American Heart Association (AHA), and Heart Rhythm Society (HRS) guidelines on the management of patients with ventricular arrhythmias note that patients who may benefit from the temporary use of a wearable cardioverter defibrillator include: patients with a permanent implantable cardioverter-defibrillator (ICD) that must be explanted, or those with a delay in implanting a newly indicated ICD; patients with reduced left ventricular (LV) systolic function [a LV ejection fraction (EF) at or less than 35%] who have undergone coronary revascularization with coronary artery b…

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the wearable cardioverter defibrillator for treatment of the enrollee’s myocardial infarction (MI). Findings: Two physician reviewers found that in this circumstance, there is potential for recovery of left ventricular ejection fraction (LVEF) over time with medical therapy. In addition, 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. Placement of a prophylactic defibrillator is not recommended until at least 90 days have elapsed with continued left ventricular dysfunction demonstrated by an ejection fraction less than 35% despite appropriate treatment. A prophylactic defibrillator before this time has not been demonstrated to improve outcome.

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 myocardial infarction, then check the rights and deadlines that apply to your plan.