Paroxysmal Atrial Fibrillation denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 62-year-old man with symptomatic paroxysmal atrial fibrillation. His condition was refractory to multiple medications. The treated condition was not coronary artery disease, but atrial fibrillation. The patient’s provider recommended he undergo pulmonary vein isolation. The treating electrophysiologist ordered electron beam angiography to assess the pulmonary veins before and after the procedure. The Health Plan has denied coverage for the electron beam angiographies on the basis the services are experimental. Electron beam angiography is a technique without a comparable equivalent. Electron beam technology provides a three-dimensional image, which is superior to the two-dimensional imaging provided by conventional, invasive angiography. Electron beam angiography was a component of the pulmonary vein isolation procedure approved for this patient.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the convergent procedure (CPT 33266). Findings: The physician reviewer found that the peer-reviewed medical literature, the convergent procedure is described to include epicardial and endocardial ablations, which are different but combined to provide a superior outcome. In one comparative study, Jan and colleagues evaluated patient outcomes with the convergent procedure and catheter ablation alone. The authors concluded that treatment of paroxysmal atrial fibrillation with the convergent procedure “showed less arrhythmia recurrence compared to catheter ablation.” In addition, Kress and colleagues demonstrated improved results with the hybrid convergent procedure in managing atrial fibrillation compared to catheter ablation.

Where the denial was upheld

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.).

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for remote monitoring services for the already inserted LINQ heart monitor for evaluation of the enrollee’s paroxysmal atrial fibrillation. Findings: The physician reviewer found that The physician reviewer found the patient has ongoing documented symptomatic paroxysmal atrial fibrillation despite medication and an ablation procedure. In this circumstance of ongoing documented paroxysmal atrial fibrillation, interrogation of a previously placed implantable loop recorder is not indicated since the diagnosis of paroxysmal atrial fibrillation is already established and the treatment is not likely to significantly change based on the results.

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 paroxysmal atrial fibrillation, then check the rights and deadlines that apply to your plan.