Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: implantable ambulatory event monitor.  
The insurer denied implantable ambulatory event monitor. 
The denial is overturned.

The patient is a male with a history of borderline hypertension and hypertrophic cardiomyopathy (HCM). His mother also has hypertrophic cardiomyopathy. An echocardiogram showed asymmetric septal hypertrophy and systolic anterior motion of the mitral valve. There was no significant left ventricular outflow tract gradient at rest; there was a gradient of greater than (>)100 millimeters of mercury (mmHg) with exercise. Cardiac magnetic resonance imaging (MRI) showed a septal thickness of 13-14 millimeter (mm). The patient complained of intermittent lightheadedness when walking up the stairs after eating a high carbohydrate meal. A 3-day cardiac event monitor showed a single episode of nonsustained ventricular tachycardia that lasted 19 beats, with an average rate of 170 beats/minute. There were no associated symptoms. Implantation of an implantable loop recorder (ILR) was recommended for further risk stratification. Medical necessity for the implantable loop recorder (ILR) is the subject under review.

The health plan's determination is overturned.

This patient has hypertrophic cardiomyopathy (HCM) and was documented to have an episode of nonsustained ventricular tachycardia (NSVT) during 3-day ambulatory monitoring. While NSVT demonstrated by short-term monitoring is a major risk factor for sudden cardiac death in HCM, given the absence of other negative prognostic indicators in this particular patient, the NSVT alone is not an indication for implantation of an implantable cardioverter defibrillator. However, his previously documented, relatively long (19 beats) episode of rapid NSVT is cause for concern. In an effort to further risk-stratify this patient, an implantable loop recorder, which would be expected to provide several years of cardiac monitoring, and an estimate of this patient's overall arrhythmia burden, has been recommended.
The medical literature supports the utility of long-term monitoring in this situation. In the report by Viswanathan, et al., the arrhythmia logs of patients with HCM and an implantable cardioverter defibrillator were reviewed. Over a median follow-up period of 61 months, more than one episode of rapid NSVT had a positive predictive value of 47% (percent) for sustained ventricular arrhythmias and a negative predictive value of 96%. In a similar study, Wang, et al., found an increased risk for sustained arrhythmia in patients with recurrent episodes of NSVT. In the report by Sakhi, et al., in patients with HCM who were otherwise deemed to be at low to intermediate risk for sudden cardiac death, at 30 months monitoring by means of an ILR resulted in a cumulative actionable event rate of 51 versus. 27% in patients who underwent intermittent Holter monitoring every 6-24 months. This included de novo atrial fibrillation that required anticoagulation for stroke prevention that was detected in 3/25 patients in the ILR group and none in the Holter group. Magnusson et al. reported a 30% incidence of previously undiagnosed atrial fibrillation, a significant predictor of stroke in patients with HCM.

The health plan's determination of medical necessity is overturned in whole.