Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial Fibrillation.

Treatment: code 93229 wearable mobile cardiovascular telemetry with electrocardiographic recording concurrent computerized real time data.

The insurer denied coverage for code 93229 wearable mobile cardiovascular telemetry with electrocardiographic recording concurrent computerized real time data.

The denial is overturned.

This is a patient with a history of ischemic heart disease and hypertension that presented to his cardiologist complaining of recurrent episodic chest pain on minimal exertion. He underwent percutaneous coronary intervention to the left circumflex artery. Following intervention, episodic chest pain prompted several visits to the emergency room for evaluation. 12 lead electrocardiogram (ECG) in the office revealed normal sinus rhythm.  Stress echocardiography revealed ischemic changes on ECG with normal wall motion and an LVEF (left ventricular ejection fraction) of 55% (percent).  Repeat cardiac catheterization with attempted revascularization of a diffusely disease right coronary artery was unsuccessful. During catheterization, the patient developed atrial fibrillation. Attempt to restore sinus rhythm with DC [direct-current] cardioversion was not successful.  A thirty day monitor with real time telemetry (code 93229) was placed to assess AF [atrial fibrillation] burden and rate control.  

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This patient had a history of ischemic heart disease and multiple visits to the hospital for recurrent episodic chest pain with exertion.  These symptoms were not present all of the time and did not resolve following left circumflex artery revascularization. An attempt to revascularize the right coronary artery was not successful, however during the procedure the patient developed atrial fibrillation with a rapid ventricular rate that could not be successfully cardioverted.  It is likely that the patient's recurrent chest pain was the result of increased myocardial oxygen demand when AF with rapid ventricular rates were present.  Elucidating this diagnosis as soon as possible in order to treat aggressively is medically necessary.  Thus, real time wearable mobile telemetry is medically necessary in this case. Mobile telemetry monitoring is an important diagnostic tool for the detection of atrial fibrillation, risk stratification or evaluation of arrhythmia symptoms. (Reference 1) 

In this case such a device would allow a physician to determine whether symptoms are due to atrial fibrillation or whether additional more complex coronary vascular intervention should be pursued.  Heart Rhythm Society guidelines note that accurate and timely diagnosis is critical to direct therapy that can make an impact on patient care and healthcare utilization (Reference 2) 

In conclusion, Wearable mobile cardiac telemetry monitoring (Code 93229) was medically necessary in this case.

Based on the above, the medical necessity for the code 93229 wearable mobile cardiovascular telemetry with electrocardiographic recording concurrent computerized real time data is substantiated. The insurer's denial is overturned.