Enhanced External Counter Pulsation denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: This patient is a 66-year-old female with coronary artery disease, diabetes and hypertension. She underwent cardiac revascularization in 2004 and became symptomatic again in April 2005 with shortness of breath and angina. The patient has requested authorization and coverage for enhanced external counterpulsation (EECP). The Health Plan has denied this request indicating the requested therapy is considered investigational. The most recent ACC/AHA practice guidelines from 2002 consider enhanced external pulsation (EECP) as a Class IIb therapy for the treatment of chronic stable angina in patients who are refractory to medical therapy who are not candidates for PTCA or surgical intervention. This means its usefulness/efficacy is less well established by evidence or opinion.

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.

Where the denial was upheld

Physician 1The patient is a 62-year-old male with a history of coronary artery disease and angina. He underwent coronary artery bypass grafting in 1988 and an angioplasty with cardiac stent placement in 1994. The patient reported experiencing chest pain in July 2004. An abnormal thallium scan showed midlateral wall ischemia. The patient’s provider recommended enhanced external counterpulsation (EECP). The Health Plan has denied authorization and coverage for EECP on the basis it is considered experimental for treatment of the patient’s medical condition.The patient has known coronary disease and angina. However, based on the submitted records of the stress test performed on 7/27/04, the patient is able to walk 8.03 on a Bruce Protocol without chest discomfort or ST changes and with appropriate augmentation of heart rate and blood pressure.

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.).

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 Enhanced External Counter Pulsation, then check the rights and deadlines that apply to your plan.