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

A 64-year-old male enrollee has requested authorization and coverage for real-time remote heart monitoring for evaluation of the enrollees atrial fibrillation.  Findings:  Two physician reviewers found that the patient has a history of atrial fibrillation and atrial flutter. Per the patient, he has undergone electrical cardioversions previously as well as catheter ablation. He is being monitored for unclear reasons but presumably, given his extensive atrial tachyarrhythmias, for rhythm evaluation. His provider has recommended further monitoring with use of an ambulatory event monitor (also known as a memory loop recorder) with real-time capabilities, also known as auto-triggered memory loop recorders. The Health Plan has denied coverage stating that the requested device is considered investigational in the evaluation and treatment of this patients medical condition.  In 2005, a study published by Reiffel and colleagues examined whether the newer auto-triggered (real-time) ambulatory monitors have higher yield for the detection of both symptomatic and asymptomatic but clinically relevant arrhythmias, when compared to traditional Holter monitors and traditional event monitors. The researchers evaluated 1800 patients in 3 groups depending on the device they received: standard Holter monitor; standard event monitor; and auto-triggered/real-time event monitor. The real-time devices provided a higher diagnostic total yield virtually for all arrhythmias, including atrial fibrillation. The authors concluded that auto-triggered/real-time devices are superior to standard event monitor devices for the detection of asymptomatic arrhythmias, including atrial fibrillation. Specifically, this study demonstrates the added value of using real-time or auto-triggering event monitors when compared to standard event monitors. A study published by Olson and colleagues examined the performance of continuous outpatient telemetry (ambulatory monitoring with real-time capability) in a clinical setting. The authors evaluated 122 patients with real-time event monitoring for a variety of clinical indications and 80% of the patients diagnosed with real-time ambulatory monitoring had a previously negative work-up with traditional means, and 16% had events detected that were completely asymptomatic. The authors concluded that real-time monitoring can detect asymptomatic clinically significant arrhythmias even in patients with a previously negative work up. In addition, this outpatient monitoring device also allowed patients to undergo daily titration of their medications based on the results of the real-time data.  This patients situation involves a clinically significant atrial arrhythmia which is likely recurrent atrial flutter. He returned with recurrent symptoms after cardioversions and ablations. Clinically relevant arrhythmias included atrial fibrillation, the arrhythmia detected by the cardiologist. Work-up with a real-time monitoring was pursued in an attempt to diagnose the arrhythmia which has important implications for the therapeutic management of this patient. From the evidence presented in the case of real-time event monitoring, there does seem to be a net clinical benefit (Elijovich, et al). Moreover, based on the peer-reviewed studies, the remote telemetry event monitor prescribed this patient has sufficient evidence to show that it is more beneficial than any standard available therapy in those with a history of suspected or established arrhythmic heart disorders, especially when standard therapy has failed.