Palpitations denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a tilt table test. The records document that this patient presented to her provider with complaints of dizziness and palpitations. The patient is noted to have a history of Ehlers-Danlos syndrome and mast cell activation syndrome. Palpitations are sensations of a rapid or irregular heartbeat and are commonly caused by cardiac arrhythmias or anxiety, though there are many other causes as well. When palpitations are accompanied by dizziness, it is considered a more serious condition that requires further assessment. The patient underwent evaluation for unexplained symptoms of dizziness and palpitations with an echocardiogram, which was normal, and Zio monitor, which demonstrated abnormal atrial tachycardia.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for an electrophysiology study using advanced electrophysiology technology, including Stereotaxis magnetic navigation systems. In this case, the patient presents with palpitations of multifactorial etiology and has complex arrhythmic status. The records indicate that serious cardiovascular disorders and rhythm disturbances have been excluded through exhaustive and repetitive testing. However, the patient continues to experience palpitations with different monitoring strategies showing various rhythm findings corresponding to the reported symptoms, and some recordings showing normal (sinus) rhythm.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a heart monitor. In this case, if cardiac monitoring were thought to be indicated to evaluate for palpitations, then non-real time (off-line) monitoring devices such as extended (48 hour) Holter monitoring or off-line event monitoring should be sufficient for the identification of both symptomatic and asymptomatic dysrhythmias including atrial fibrillation. Continuous off-line 24-to-48 hour Holter monitoring should be able to effectively identify symptomatic or asymptomatic dysrhythmias that occur frequently. Likewise, self-activated non-real time and non-continuous monitoring devices (event recorders) should be effective at recording symptomatic dysrhythmias during less frequent symptoms.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the blood test, advanced lipoprotein testing for evaluation of the enrollee, who presented with heart palpitations. Findings: The physician reviewers found that The patient no prior history of heart disease. She presented with four to five week history of intermittent palpitations and anxiety. Her blood pressure, pulse and cardiopulmonary examinations were normal. The patient’s resting electrocardiogram (EKG) was also normal. The patient’s provider referred the patient for blood testing including chemistries, standard lipids profiles, advanced lipoprotein studies and advanced coagulation and metabolic studies. Per the Health Plan, the services at issue were investigational for the evaluation of this patient.

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