Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 47-year-old male with ischemic cardiomyopathy. He has an ejection fraction (EF) of 35% and is status post Automatic Implanted Cardiac Defibrillator (AICD) placement.  He is reportedly on optimal therapy for heart failure and underwent bioimpedance testing for assessment of his fluid status in April, 2005.  The patient now requests reimbursement for the diagnostic procedure.  The Health Plan considers bioimpedance testing experimental/investigational and has denied coverage.The following is an excerpt from the most recent American College of Cardiology/ American Heart Association Practice Guidelines for heart failure (HF):There has been no established role for periodic invasive or noninvasive hemodynamic measurements in the management of HF. Most drugs used for the treatment of HF are prescribed on the basis of their ability to improve symptoms or survival rather than their effect on hemodynamic variables. Moreover, the initial and target doses of these drugs are selected on the basis of experience in controlled trials and are not based on the changes they may produce in cardiac output or pulmonary wedge pressure. Nevertheless, invasive hemodynamic measurements may assist in the determination of volume status and in distinguishing HF from other disorders that may cause circulatory instability, such as pulmonary diseases and sepsis. Measurement of cardiac output and pulmonary wedge pressure through a pulmonary artery catheter have also been used in patients with refractory HF to assess pulmonary vascular resistance, a determinant of eligibility for heart transplantation. Cardiac output can also be measured by noninvasive methods.As stated above, bioimpedance testing is not currently indicated for titration of medications. This recommendation may change in the future if clinical trials support the usefulness of the procedure. Based on current guidelines, I find that the procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 47-year-old male diagnosed with ischemic cardiomyopathy. He underwent bioimpedance testing in April, 2005 to assess his hemodynamic status and to titrate his cardiac medications. The patient now requests reimbursement for the procedure. The Health Plan deems bioimpedance testing experimental/investigational and the patients request for reimbursement was denied.Peer reviewed medical literature has not demonstrated the clinical efficacy of impedance cardiography for the management of cardiomyopathy in the outpatient setting. Additionally, impedance cardiography is not superior to conventional testing (echocardiography and cardiac catheterization) in the initial assessment of cardiomyopathy.  Therefore, I have determined that the procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 47-year-old male with a history of ischemic cardiomyopathy and a reduced ejection fraction.  On the date of the bioimpedance testing, his provider noted complaints of daytime somnolence and a poor energy level.  The patient proceeded with bioimpedance testing and is now requesting reimbursement. The Health Plan deemed the procedure experimental/investigational and therefore denied reimbursement.Bioimpedance testing is most commonly performed to assess cardiac output and fluid status in the office setting. The American Heart Association / American College of Cardiology has not taken the position that bioimpedance testing is necessary in the standard treatment of heart failure. In this situation, it is unclear how bioimpedance testing would really affect the patients care. His symptoms of daytime sleepiness and poor energy are more consistent with sleep apnea than with volume overload. A B-type Natriuretic Peptide (BNP) test was also ordered.  The standard medical alternatives for further workup would be a sleep study to evaluate the somnolence, clinical assessment of fluid status (weight, chest x-ray and physical examination) and titration of medications.  We are still awaiting large clinical trials demonstrating the prognostic impact of bioimpedance testing in the management of heart failure. Given the documentation provided, and the currently available clinical trials, I have determined that the procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.