Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #3:

Diagnosis: Patent foramen ovale (PFO)

Treatment: procedure code 93580, transcatheter closure of a PFO using a cardiac occlusion device

The insurer denied coverage for procedure code 93580, transcatheter closure of a PFO using a cardiac occlusion device

The denial is overturned

The patient is aa adult seeking authorization for 93580, transcatheter closure of a patent foramen ovale (PFO) using a cardiac occlusion device.

The patient underwent transesophageal echocardiogram (TEE) due to cerebral infarction, unspecified. The findings noted a small patent foramen ovale.

The patient sustained a stroke. Comprehensive work-up determined that stroke occurred from paradoxical embolus after Valsalva in the presence of a PFO. The provider recommended PFO closure for secondary stroke prevention.

The patient was seen for a follow-up evaluation related to foramen ovale (PFO) and cryptogenic stroke. Comorbidities included dyslipidemia and hypertension. The patient stroke work-up had been unremarkable except for a PFO, documented as having a small shunt on transesophageal echocardiogram (TEE). As TEE typically under-calls the degree of shunt due to a patient having a possible component of dehydration, and inability to Valsalva efficiently due to sedation. The patient returned for transcranial Doppler testing which was the most accurate way to quantify the degree of right to left shunt. Medication list included aspirin, lisinopril, and rosuvastatin. The patient's height was documented as 6 feet and 1 inch with a weight of 249 pounds. The patient underwent transcranial doppler to evaluate for atrial/pulmonary right to left shunt. The findings represented the presence of a right to left atrial septum/pulmonary shunt. During normal respiration, there was a right to left shunting that was grade 1. After Valsalva strain, there was right to left shunting of grade 4. The provider noted that this supported moderate to large right to left shunt. The fact that the patient's resting transcranial Doppler had a smaller shunt was reflected by the transesophageal echocardiogram results. Patent foramen ovale (PFO) closure was recommended.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes.

The 93580, transcatheter closure of a patent foramen ovale using a cardiac
occlusion device has final approval from the appropriate regulatory bodies for this diagnosis. 

This patient is a good candidate for procedure code 93580, transcatheter closure of a patent foramen ovale using a cardiac occlusion device. 

The 93580, transcatheter closure of a patent foramen ovale using a cardiac occlusion device is the best available treatment for this patient. 

There adverse risks are not increased over standard treatment/services. 

The requested treatment is likely to be more beneficial than any other standard treatments/procedures for this patient. 

As such, the requested PFO closure is the best treatment available for the patient. Therefore, the denial of 93580, transcatheter closure of a patent foramen ovale (PFO) using a cardiac occlusion device is overturned.

In summary, the denial of procedure code 93580, transcatheter closure of a patent foramen ovale (PFO) using a cardiac occlusion device and coverage for the requested service/treatment should be reversed. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.