EECP Dvc denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 63-year-old man with angina refractory to medical therapy, status post two previous bypass surgeries in 1983 and 2000. The patient was found not to be a candidate for repeat revascularization procedures by cardiac catheterization in December 2003. The patient has recurrent chest discomfort on minimal exertion (Canadian Class 3 to 4 symptoms by description). The patient underwent enhanced external counterpulsation (EECP) in 2004. The Health Plan has denied reimbursement for EECP therapy on the basis it is considered investigational.This patient presented with refractory angina that was unable to be controlled by medical therapy. The use of EECP in this setting is a well-known, clinically accepted and appropriate treatment for patients in this exact subset.

A 56-year-old male enrollee has requested enhanced external counterpulsation for the treatment of his multiple cardiac problems. Findings: Two physician reviewers found that the use of enhanced external counterpulsation (EECP) in chronic angina patients who cannot be safely re-vascularized and are refractory to medications is accepted as a medically appropriate treatment modality. The current American College of Cardiology (ACC) guidelines for the treatment of chronic angina specifically consider the use of EECP in this patient population. The ACC classification of this recommendation for EECP recognizes that the indications for the use of EECP are still being studied. Gibbons and colleagues found in their study that EECP was generally well tolerated and efficacious with approximately 75% to 80% of patients reporting improvement in symptoms.

Where the denial was upheld

Physician 1: The patient is a 62-year-old male who is reported to have small vessel disease, not amenable to revascularization. The cardiac catheterization describing the anatomy is not in the documentation provided. His angina is atypical, occurring at rest, but it is reported that he does not generally get chest discomfort while doing exercises. He is only on a beta-blocker for angina. He is also able to use an easy-glider for about half-an-hour a day. The patient’s provider has requested authorization for enhanced external counterpulsation (EECP) therapy, which has been denied by the Health Plan.The most recent American Heart Association (AHA) guidelines in 2002 list EECP as a class IIb therapy or “usefulness/efficacy is less well established by evidence/opinion” (Gibbons, et. al.).

A 67-year-old female enrollee has requested EECP therapy for treatment of the enrollee’s angina. Findings: Three physician reviewers found that this patient has persistent chest symptoms after stenting of the LAD and diagonal branches. However, by both invasive and non-invasive assessment, there is no objective evidence of significant residual ischemia. Medical therapy has been recommended, and she has responded very well to Ranexa with control of chest symptoms. The other option recommended was EECP therapy. EECP therapy remains a Class IIB indication by American College of Cardiology guidelines.

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