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

Physician 1: This case involves a 49-year-old male who has a history of ischemic heart disease. He experienced a heart attack in 2001. The patient twice underwent stenting of the proximal left ascending coronary artery and now has a pre-stent lesion with 95% occlusion. He has requested authorization and coverage for robotic assisted coronary artery bypass surgery. The Health Plan has denied this request on the basis the requested procedure is considered investigational for treatment of the patients medical condition.There are many articles demonstrating the safety and efficacy of single vessel bypass of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) with robotic assisted surgery. This procedure is no longer considered experimental. Robotic assisted coronary artery bypass is superior to conventional surgery in that it results in less pain and a shorter hospital stay. In addition, there is no stenting incision and no infection with the robotic assisted procedure. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: The patient is a 49-year-old male with a left anterior descending artery (LAD). He is status post metal stent with brachytherapy and a coated stent. Given this anatomy, coronary artery bypass grafting (CABG) has been recommended. Options for single vessel bypass include standard CABG on bypass pump; CABG off bypass pump using a cradle; and minimally invasive CABG using non-sternotomy techniques. In this case the patients provider has recommended use of the DaVinci or robotic technique. The submitted documentation notes no overriding problems such as prior CABG, mitral valve disease or anatomic issues. At issue is whether robotic assisted CABG is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Robotic assisted surgery is a promising field. Small case series have been published involving robotic assisted surgery for mitral valve repair. To date, there has not been a large series of studies showing the superiority of robotic assisted surgery over traditional CABG. Despite its appeal, the advantages and disadvantages of robotic assisted CABG have not been clearly established. Currently, robotic assisted CABG is an investigational procedure requiring further study. Given the available medical literature, robotic assisted CABG is not likely to be superior to traditional CABG for treatment of this patients coronary artery disease. Furthermore, the requested procedure is not medically necessary for this patient as he can be appropriately treated with a traditional CABG procedure. Accordingly, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 49-year-old male with hyperlipidemia status post coronary stenting who developed LAD disease proximate to the previously placed drug-eluting stent. There is no evidence of any other disease in the coronaries. Since the disease is confined to a single vessel the patient wishes to undergo minimally invasive coronary revascularization using robotic assisted artery bypass with off-pump anastomosis.The minimally invasive off-pump coronary artery bypass has been used extensively since the late 1990s and is not considered to be investigational. However, its early and late follow-up results do not necessarily show any significant improvement over standard on-pump bypass. Furthermore, harvesting the internal mammary artery (IMA) using the robotic system is also not considered investigational. However, there is no data in the peer-reviewed literature comparing robotic assisted harvesting to either mini-thoracotomy or stenotomy for off-pump bypass. As such, it has not been established that robotic harvesting of the IMA has any benefit over other techniques used during single-vessel revascularization of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) off-pump. In addition, the superiority of off-pump bypass versus on-pump bypass has not been clearly established with data suggesting increased late failure rates with the off-pump procedure.In summary, robotic assisted artery bypass has not been shown to be superior to other minimally invasive techniques for IMA harvesting and is not medically necessary in the case of this patient. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.