Premature Ventricular Contractions denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for mobile cardiac outpatient telemetry. Mobile cardiac outpatient telemetry (MCOT) has emerged as a standard tool in the evaluation of patients with suspected cardiac arrhythmia. While traditional Holter monitors provide continuous electrocardiogram (ECG) monitoring, this modality is generally only available for 24 to 48 hours. Current MCOT systems with advanced technology permit nearly continuous, automatic, and, with some systems, real-time monitoring. These systems are often smaller and less intrusive to patients, leveraging patch-style devices rather than cumbersome, multi-lead systems.

A 62-year-old male enrollee has requested reimbursement for coronary computed tomography (CT) angiogram for evaluation of the enrollee’s irregular heartbeat. Findings: Two physician reviewers found that the patient has a history of multiple premature ventricular contractions (PVCs) gastro-esophageal reflux disease, polycythemia vera, deep vein thrombosis (DVT) and pulmonary emboli. He was found to have an irregular heart rhythm during routine pre-operative evaluation for foot surgery and was referred to a cardiologist. He was found to have frequent PVCs on Holter testing. An exercise nuclear stress test revealed findings that were equivocal for ischemia with upsloping ST depression and equivocal perfusion findings. He was then instructed to undergo a coronary computed tomography (CT) angiogram to evaluate whether he had any underlying coronary artery disease.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for an external electrocardiogram (ECG) monitoring device. On review of the medical literature and this patient’s records, the external ECG monitoring device was not likely to be more beneficial than standard devices, including a 24- or 48-hour Holter monitor, in diagnosing the patient’s condition. The patient had no reported previous cardiac history and was incidentally noted to have an irregular heartbeat with premature ventricular contractions on a rhythm strip. The mobile cardiac event monitor provides immediate evaluation and transmission of data, which was not indicated for this patient’s evaluation. Instead, a standard Holter monitor with recording would have been sufficient to determine the frequency and extent of premature ventricular contractions.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services, specifically the use of a real time heart monitor for evaluation of the enrollee who presented with premature ventricular contractions. Findings: The physician reviewers found that the documentation provided does not support the superior efficacy of the services at issue in this clinical setting. The records provided indicate that this patient had intermittent palpitations. In this circumstance, if additional evaluation for a dysrhythmia is thought to be necessary then prolonged serial 48 hour Holter monitoring or off line self activated or auto triggered cardiac event monitoring should be sufficient in recording cardiac rhythm during symptoms.

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 premature ventricular contractions, then check the rights and deadlines that apply to your plan.