EKG denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a stress echocardiogram. Based on the submitted records, this patient presents with increased coronary risk in addition to symptoms of palpitations and exertional dyspnea concerning for an anginal equivalent and/or left ventricular dysfunction. In this circumstance, further evaluation to assess for left ventricular dysfunction and coronary ischemia is medically appropriate. An imaging stress test is appropriate to evaluate for both left ventricular dysfunction and coronary ischemia in the same procedure. Stress echocardiography is indicated based on the patient’s symptoms, regardless of upcoming low risk non-cardiac hysterectomy surgery. Current guidelines endorsed by several national organizations consider stress echocardiography appropriate in this setting.

A 55-year-old female enrollee has requested real-time cardiac monitoring for evaluation of her mitral valve prolapse. Findings: Two physician reviewers found that remote ambulatory long-term cardiac monitoring is now recognized and accepted as a useful diagnostic adjunct to detecting and characterizing underlying symptomatic and asymptomatic cardiac arrhythmias, for both risk assessment and to inform best management on a real-time basis. In most settings, the information obtained is not easily or promptly ascertained using other diagnostic approaches. In this patient with significant arrhythmias detected at the time of stress testing, the services at issue were medically appropriate even absent test evidence for ischemia. It is true that the value of remote monitoring remains to be definitively established.

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).

Nature of Statutory Criteria/Case Summary:The parent of a 10-year-old male enrollee has requested authorization and coverage for an echocardiogram for treatment of the enrollee’s chest pain. Findings: The physician reviewer found that At issue in this case is whether the requested echocardiogram is medically necessary for treatment of the enrollee’s medical condition.Per Hussain and colleagues, chest pain is a reasonably common complaint in the pediatric population. In terms of referral to pediatric cardiology, it ranks second only to heart murmurs. The most common cause is idiopathic, occurring in up to half of cases. Other causes include pulmonary, musculoskeletal, gastrointestinal, and psychological. Actual cardiac causes are present in less than 5% of cases. Most children have normal physical exam findings.

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