Real Time Heart Monitor denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for a real time heart monitor for evaluation of the enrollee’s heart murmur. In young patients it is difficult to differentiate cardiac versus non-cardiac causes of syncope. Patients may present with seizure-like activity even though the primary issue is not neurologic. In this patient’s case, his seizure-like activity is being considered as potentially of cardiac origin. An evaluation is currently underway, including a period of ambulatory cardiac monitoring. Ambulatory electrocardiography monitors, or real time heart monitors, are devices designed for use at home to record the electrical activity of the heart while the patient is performing normal daytime activities.

A 46-year-old female enrollee has requested for use of a real-time heart monitor evaluation of her hypertrophic cardiomyopathy. Findings: Two physician reviewers found that the use of a real-time heart monitor was likely to have been of greater efficacy than other modalities for evaluating this patient. Reiffel and colleagues examined whether the newer auto-triggered (real-time) ambulatory monitors have higher yield for the detection of both symptomatic and asymptomatic arrhythmias when compared to traditional Holter monitors and traditional event monitors. The authors concluded that auto-triggered/real-time devices are superior to standard event monitor devices for the detection of asymptomatic arrhythmias, including atrial fibrillation.

Where the denial was upheld

A 64-year-old male enrollee has requested a Real-Time Heart Monitor for the treament of his paroxysmal supraventricular tachycardia and syncope. Findings: Two physician reviewers found that based on the records provided, the patient underwent two weeks of continuous outpatient mobile cardiac telemetry to assess for a cause of syncope under the diagnosis code of paroxysmal supraventricular tachycardia. In this circumstance, if cardiac monitoring were thought to be medically necessary then non-real time (off-line) monitoring devices such as Holter monitoring or event monitoring should be sufficient for identification of both symptomatic and asymptomatic dysrhythmias. Continuous off-line 24-48 hour Holter monitoring should be able to effectively identify symptomatic or asymptomatic dysrhythmias that occur frequently.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services, specifically the use of a real time heart monitor for evaluation of the enrollee who presented with premature ventricular contractions. Findings: The physician reviewers found that the documentation provided does not support the superior efficacy of the services at issue in this clinical setting. The records provided indicate that this patient had intermittent palpitations. In this circumstance, if additional evaluation for a dysrhythmia is thought to be necessary then prolonged serial 48 hour Holter monitoring or off line self activated or auto triggered cardiac event monitoring should be sufficient in recording cardiac rhythm during symptoms.

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 Real Time Heart Monitor, then check the rights and deadlines that apply to your plan.