Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory-paroxysmal atrial fibrillation and atrial tachycardia.
Treatment: Surgical Services-cardiac ablation. 
The insurer denied cardiac ablation. 
The denial is overturned in whole.

The patient is a female with a history of infective endocarditis that was associated with paroxysmal atrial fibrillation and atrial tachycardia. She was evaluated complaining of recurrent episodes of tachycardia associated with weakness. She reported having had 4-6 episodes over the preceding three months as well as similar episodes. A 30 day event monitor was ordered. This showed two episodes of a regular, narrow complex tachycardia with rates from 169-191 beats/minute. The episodes were self-terminating; the longest lasted approximately 13 seconds. There was one approximately three second run of an irregular narrow complex tachycardia that was interpreted as atrial fibrillation and another five beat run of an irregular narrow complex tachycardia that was labeled as "atrial run". The patient was referred to the cardiologist who saw her. Per his note, the patient had been having frequent symptomatic episodes of paroxysmal atrial fibrillation (AF) and was intolerant to medical therapy, including beta-adrenergic blockers. An echocardiogram showed preserved left ventricular systolic function and catheter ablation for AF was recommended. Per the appeal letter from the nurse practitioner, an ablation was recommended for supraventricular tachycardia documented by event monitoring. The subject under review is the medical necessity for the ablation for paroxysmal supraventricular tachycardia.  

The health plan's determination is overturned.

The cardiac ablation for paroxysmal supraventricular tachycardia is medically necessary for this patient.
The patient's event monitor showed episodes of paroxysmal supraventricular tachycardia (PSVT), for which she was referred to the cardiologist.  The clarification provided by the client specifies exactly which type of catheter ablation is planned.  Previously there was a discrepancy in the records provided as the cardiologist's note indicated that the patient had frequent atrial fibrillation (AF) and ablation for AF was planned.  This was in contradiction to the other medical records and the nurse practitioner appeal letter.
The clarification indicates that catheter ablation for paroxysmal supraventricular tachycardia (PSVT) is planned.  This is appropriate given the arrhythmia documented on the patient's ambulatory electrocardiographic monitor and the nurse practitioner's appeal letter that indicated that the patient has frequent episodes of symptomatic paroxysmal supraventricular tachycardia.  She has been intolerant to pharmacologic therapy.  Per the American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) Guideline for the Management of Adult Patients With Supraventricular Tachycardia catheter ablation is considered first-line therapy for patients with symptomatic PSVT as it is likely to be curative, with a favorable risk: benefit ratio, and is likely to obviate the need for ongoing antiarrhythmic drug therapy.