Wearable Cardioverter Defibrillator denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a wearable cardioverter defibrillator (automatic external defibrillator with integrated electronic cardiogram analysis, garment type). This patient has non-ischemic cardiomyopathy (NICM) and given his son’s condition and course, genetic testing has been performed to determine a causative etiology and to direct clinical prognosis, with results pending. As no other etiology of NICM is evident, it may be presumed that this patient has titin (TTN)-related NICM until results of genetic testing become available. While patients with NICM are at increased risk of arrhythmic sudden death, patients with TTN-related cardiomyopathy appear to be at especially high risk for life-threatening rhythm disturbances.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wearable cardioverter defibrillator (WCD) for three months. Findings: The physician reviewer found that documented high risk of sudden cardiac death in patients with severe left ventricular dysfunction has led to the development and recommendation for treatment with implantable cardioverter defibrillators. Current data from multiple trials have advocated the use of a WCD after an initial diagnosis of severe left ventricular dysfunction with an ejection fraction (EF) of 35% or less along with guideline directed medical therapy.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the wearable cardioverter defibrillator for treatment of the enrollee’s dilated cardiomyopathy. Findings: The physician reviewer found that Based on the records provided the patient presented with newly recognized severe left ventricular dysfunction in the setting of troponin elevation, respiratory failure and no obstructive coronary disease. In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy and there was no documented indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia or aborted sudden cardiac arrest.

Nature of Statutory Criteria/ Case Summary: The enrollee requested reimbursement for the wearable cardioverter defibrillator LifeVest. According to the records, the enrollee has a past medical history of coronary artery disease, diabetes mellitus type 2, hyperlipidemia, and ischemic cardiomyopathy with ejection fraction (EF) of 30%. A previous angiogram showed severe disease in the left anterior descending (LAD) artery (100%)/obtuse marginal (OM2) (90%). The enrollee was put on a LifeVest for sudden cardiac death (SCD) prevention and recommended to undergo surgical revascularization of his coronary arteries of Impella assisted complete percutaneous coronary intervention (PCI). The requesting provider noted the enrollee needed to be medically optimized and reassessed after the waiting period as to the need for automated implantable cardioverter defibrillator (AICD).

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 Wearable Cardioverter Defibrillator, then check the rights and deadlines that apply to your plan.