Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Non-ischemic cardiomyopathy

Treatment: Internal cardiac defibrillator (ICD)

The insurer denied coverage for internal cardiac defibrillator (ICD). The denial reversed.

This patient is a female who presented follow-up of her dilated cardiomyopathy. She claimed that she was feeling okay but had several episodes of syncope that occurred when she stood quickly and was preceded by dizziness. She did not complain of any palpitations. Recently she had her diuretic dose increased based on an elevated brain natriuretic peptide (BNP). Her medications at that time included Klonopin, Digoxin and Prozac. She was also prescribed the following medications:  Lasix, Metoprolol, Xarelto, Crestor and Aldactone. Her vital signs were: blood pressure 104/64, pulse 78, oxygen saturation 98% and body mass index (BMI) 21.88. 

On physical exam she was described in no acute distress and there was minimal jugular vein reflux. No other abnormalities were noted. A transthoracic echocardiogram was done and showed the left ventricle was severely dilated and there is global thinning of the left ventricular walls. There is mild mitral regurgitation (MR) and the left ventricular ejection fraction is severely reduced and is less than 25%. The right ventricle ejection fraction is normal. There is severe grade 4 diastolic dysfunction. There is no pericardial effusion. The patient was taken to the ED laboratory and had implantation of a biventricular ICD. She also had placement of a left ventricular lead in the posterior lateral branch of the coronary sinus. These two procedures were done successfully.

A study was done to compare outcomes between patients with and without super-response to cardiac resynchronization therapy-defibrillator (CRT-D).  In this cohort study, 167 consecutive CRT-D candidates were included.  Super-response to CRT-D was defined clinically [improvement of >=1 New York Heart Association (NYHA) class or >=50 m in six-minute walk distance (6MWD)] and echocardiographically [increase of left ventricular ejection fraction (LVEF) >=1 category (LVEF <30 to 30-40 % or 30-40 to 41-51 %) or reduction of left ventricular end-diastolic diameter (LVEDD) >=10 mm]. The clinical outcome (death, cardiac transplantation and appropriate shock therapy) was compared between super-responders (n = 32) and non-super-responders (n = 135). They conclude that super-response to CRT-D is associated with improved survival and lower risk of appropriate shock therapy compared to non-super-responders. Further information about the mechanisms of super-response and its long-term consequences are needed to foresee favorable outcomes after implantation of 
CRT-D. (2)

This patient underwent implantation of a cardiac resynchronization therapy defibrillator (CRT-D). The limited clinical information that was present in the chart indicates that she has nonischemic cardiomyopathy and well-documented complete left bundle-branch block with a QRS interval of 143 msec. The echocardiogram also documented left ventricular systolic dysfunction with an ejection fraction less than 25%. She was taking appropriate medications to treat her heart failure symptoms. This review of the record indicates that the implantable cardioverter defibrillator provided was medically necessary for this patient. 

The health plan did not act reasonably and with sound judgment or in the best interest of the patient.

Based on the above, the medical necessity for the ICD provided is substantiated.  The insurer's denial is reversed.