Cardiac Mapping denials: what the review data shows

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 catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision, and interpretation. The records document that this patient presents with multiple cardiac risk factors including hypertension, hyperlipidemia, coronary artery disease (CAD), and congenital heart disease status post perimembranous ventricular septal defect (VSD) repair and previous coronary artery bypass graft (CABG) x 3. The patient’s work-up for symptoms including dyspnea on exertion showed abnormal results with a large area of severe ischemia with moderate LV dysfunction of 44%. The patient’s provider has recommended coronary angiography.

Where the denial was upheld

A 46-year-old female enrollee has requested reimbursement for mobile cardiac outpatient telemetry (MCOT) for evaluation of the enrollee’s cardiac condition. Findings: The physician reviewer found that based on the records provided, the patient had symptoms of palpitations in the setting of normal ventricular function and no provokable ischemia noted on a stress echocardiography. In this circumstance, if additional monitoring for a cardiac dysrhythmia were thought to be medically necessary then non-real time (off-line) monitoring devices such as extended or serial Holter monitoring or event monitoring would be sufficient for identification of both symptomatic and asymptomatic dysrhythmias. Continuous off-line 24 to 48 hour Holter monitoring should be able to effectively identify symptomatic or asymptomatic dysrhythmias that occur frequently.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for myocardial strain imaging. Based on the records, the patient has rare palpitations, a systolic heart murmur, and a family history of potentially inheritable dilated cardiomyopathy. In this circumstance, an echocardiogram is reasonable and appropriate according to current guidelines. However, while myocardial strain imaging may add additional information above that which is obtained with a standard echocardiogram, its incremental value is currently not well defined. For example, while myocardial strain imaging may serve some prognostic value, treatment change based on strain results have not been shown to improve cardiac outcome in any controlled trials.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Cardiac Mappingwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.