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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for a real time heart monitor for evaluation of the enrollees heart murmur. In young patients it is difficult to differentiate cardiac versus non-cardiac causes of syncope. Patients may present with seizure-like activity even though the primary issue is not neurologic. In this patients case, his seizure-like activity is being considered as potentially of cardiac origin. An evaluation is currently underway, including a period of ambulatory cardiac monitoring. Ambulatory electrocardiography monitors, or real time heart monitors, are devices designed for use at home to record the electrical activity of the heart while the patient is performing normal daytime activities. The purpose of real time heart monitoring is to detect cardiac arrhythmia and is useful for patients that have intermittent arrhythmias not detectable by standard electrocardiogram. These monitors are different from event monitors or loop recorders in that they do not require the patient to trigger the device. They also differ in that all of the information is transmitted to a central monitoring station rather than recording bits of data to be downloaded at a later date. In this situation, with the unpredictability of the events, the frequency of events, and the patients age, real time heart monitoring was more likely to provide the necessary information and will allow the provider to identify patterns in heart rate and rhythm surrounding spells in a way that Holter monitoring and loop recording cannot. Moreover, the patient cannot trigger the device and it is unclear if there are any behaviors or scenarios that are predictive of a spell, and the potentially useful information surrounding each spell exceeds the amount of information saved with other methods of long-term monitoring. Accordingly, the real time heart monitor was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the device at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Physician reviewer number one is board certified in pediatrics and pediatric cardiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in pediatrics and pediatric critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in pediatrics and pediatric critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.