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

Physician 1: The patient is a 62-year-old man with symptomatic paroxysmal atrial fibrillation. His condition was refractory to multiple medications. The treated condition was not coronary artery disease, but atrial fibrillation. The patients provider recommended he undergo pulmonary vein isolation. The treating electrophysiologist ordered electron beam angiography to assess the pulmonary veins before and after the procedure. The Health Plan has denied coverage for the electron beam angiographies on the basis the services are experimental. Electron beam angiography is a technique without a comparable equivalent. Electron beam technology provides a three-dimensional image, which is superior to the two-dimensional imaging provided by conventional, invasive angiography. Electron beam angiography was a component of the pulmonary vein isolation procedure approved for this patient. Evaluation of the pulmonary veins via electron beam angiography is likely to be more effective than standard imaging modalities. As such, I have determined that the services at issue were and are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Thus, Health Plans denial should be overturned. Physician 2: The patient has symptomatic paroxysmal atrial fibrillation refractory to medication. Pulmonary vein ablation was scheduled and an electron beam angiography was ordered to assess pulmonary vein anatomy before the procedure. A second electron beam angiography is scheduled 90 days after the procedure to rule out pulmonary vein stenosis. It should be noted the procedure is not being performed to assess coronary calcification. The Health Plan has denied coverage for the two electron beam angiographies on the basis such services are considered experimental.Pulmonary vein ablation requires a detailed assessment of pulmonary vein anatomy to help guide the procedure and to minimize the risk of pulmonary vein stenosis. Most centers that perform this procedure routinely obtain CT scans with three-dimensional reconstruction of the pulmonary veins for this purpose. This typically can be accomplished using a multidetector CT scanner and does not require an electron beam CT scanner. Also, the CT scan does not need to assess wall motion, which was involved in the procedure that took place in November 2004. Accordingly, I have determined that the services at issue were and are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Physician 3: The patient is a 62-year-old male with a long history of paroxysmal atrial fibrillation. He had been treated with multiple antiarrhythmic medications in an attempt to control the atrial fibrillation, but he continued to have intermittent arrhythmias. His general cardiologist referred him to a cardiologist with specialized training and experience in the treatment of cardiac arrhythmias. The cardiologist recommended that the patient undergo an ablation procedure, including electron beam angiography to be performed during and after the procedure. The Health Plan has denied coverage for the electron beam angiographies indicating that the efficacy of this technology has not been established. These ablation procedures for atrial fibrillation have been performed for the last several years and involve the destruction of cells in the area of the pulmonary veins, the four structures that carry blood from the lungs into the left atrium of the heart. If, in fact, the atrial fibrillation is originating from the pulmonary veins, this type of ablation is likely to be very successful. However, the major complication of pulmonary vein ablation is stenosis of a pulmonary vein. The likelihood of such a complication (which requires additional invasive procedures and possibly surgery to correct) is diminished by imaging of the anatomy of the pulmonary veins, which can vary greatly from patient to patient. It is for this reason that in the last few years electron beam angiography and MRI imaging of the left atrium and pulmonary veins have been used prior to an atrial fibrillation pulmonary vein ablation procedure with a repeat study performed several months later.  Thus, the use of electron beam angiography to image the pulmonary veins prior to and after the patients pulmonary vein atrial fibrillation procedure is medically appropriate and reasonable. Accordingly, I have determined that the services at issue were and are 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.