Implantable Loop Recorder denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for an implantable ambulatory event monitor. The records provided for review document that this patient experienced episodes of dizziness prior to the syncopal episodes. Evaluation with a Holter monitor several months before was unrevealing. He presented with chest pain followed by recurrent acute syncopal episodes and he was noted to be in atrial fibrillation, which responded to chemical cardioversion. He was evaluated for underlying causes of syncope including coronary artery disease (CAD). An echocardiogram demonstrated normal left ventricle (LV) function. The recurrent episodes of syncope, prior negative Holter results, and history of known paroxysmal atrial fibrillation supported concern for an arrhythmic cause of his syncope.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ambulatory event heart monitor.Findings: Two of the three physician reviewers found that this patient has significant ischemic heart disease. He has had recurrent symptoms of dizziness and near syncope which required hospital admission. He has a history of multiple embolic events. Given the underlying heart disease, the recurrent symptoms necessitating admission and the prior multiple embolic events, the likelihood of a significant rhythm disturbance, like atrial fibrillation or bradycardia, is relatively high. In the absence of any findings on the external event monitor and in the setting of recurrent symptoms requiring readmission to the hospital, evaluation with an implantable loop recorder was a reasonable next clinical step. There is sufficient support for the device at issue in this setting.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an implantable heart monitor. Based on the records provided for review, the patient had symptomatic atrial flutter treated with an ablation without recurrent heart racing symptoms. In this circumstance, if evaluation for dysrhythmias is thought to be indicated, then Holter monitoring for frequent symptoms or offline self-activated event monitoring for less frequent symptoms should be sufficient in recording cardiac rhythm during palpitations. In addition, offline auto-triggered event recorders should be effective in identifying asymptomatic paroxysmal dysrhythmias. There is no documentation to indicate the patient is not able to effectively manage these types of devices or that these devices have already been tried and failed.

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the implantable ambulatory event monitor for evaluation of the enrollee’s atrial fibrillation. Findings: The physician reviewer found that based on the records provided the patient is a 67-year-old female with a history of symptomatic paroxysmal atrial fibrillation. In this setting of symptomatic atrial fibrillation manifested by frequent palpitations identification of cardiac rhythm during symptoms should be able to be effectively accomplished by off-line monitoring devices such as serial Holter monitors, patient-activated event monitors or auto-triggered event monitors. The records provided do not indicate the patient is unable to manage these devices or that these devices have been tried and failed.

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 Implantable Loop Recorder, then check the rights and deadlines that apply to your plan.