Syncope: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for a real time heart monitor for evaluation of the enrollee’s heart murmur. In young patients it is difficult to differentiate cardiac versus non-cardiac causes of syncope. Patients may present with seizure-like activity even though the primary issue is not neurologic. In this patient’s case, his seizure-like activity is being considered as potentially of cardiac origin. An evaluation is currently underway, including a period of ambulatory cardiac monitoring. Ambulatory electrocardiography monitors, or real time heart monitors, are devices designed for use at home to record the electrical activity of the heart while the patient is performing normal daytime activities.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gene testing. This patient’s provider has recommended whole exome sequencing to assist in this patient’s diagnosis and treatment given his history of autism, intellectual disability, syncope, hallucinations, and arachnoid cyst. Whole exome sequencing is a comprehensive test, which identifies changes in a patient’s DNA that are causative or related to their medical concerns. In contrast to current sequencing tests that analyze one gene or small groups of related genes, exome sequencing analyzes the exons or coding regions of over 20,000 genes. Neurodevelopmental disorders are often complex clinical scenarios attributed to single-gene mutations that may be detected through exome sequencing.

Where the denial was upheld

A 29-year-old male enrollee has requested ambulatory event monitor with real time analysis for treatment of his syncope. Findings: Three physician reviewers found that there is limited data available in the medical literature regarding ambulatory cardiac event monitoring with real time analysis. At this time, there are no guidelines to assess the incremental diagnostic yield and subsequent improvement in clinical outcomes using this technology, especially in the initial evaluation of a first syncopal episode. The largest multi-center controlled trial to date using real time event monitoring included 266 patients with persistent symptoms who had previously undergone prior Holter monitoring which failed to diagnose an arrhythmia (Rothman and colleagues).

A 64-year-old male enrollee has requested a Real-Time Heart Monitor for the treament of his paroxysmal supraventricular tachycardia and syncope. Findings: Two physician reviewers found that based on the records provided, the patient underwent two weeks of continuous outpatient mobile cardiac telemetry to assess for a cause of syncope under the diagnosis code of paroxysmal supraventricular tachycardia. In this circumstance, if cardiac monitoring were thought to be medically necessary then non-real time (off-line) monitoring devices such as Holter monitoring or event monitoring should be sufficient for identification of both symptomatic and asymptomatic dysrhythmias. Continuous off-line 24-48 hour Holter monitoring should be able to effectively identify symptomatic or asymptomatic dysrhythmias that occur frequently.

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 syncope was denied, the published record says the denial is worth fighting.