Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Atrial Fibrillation.
Treatment: Endoscopy ablation (procedure to restore normal heart rhythm).
The insurer denied endoscopy ablation (procedure to restore normal heart rhythm).
The determination is overturned.

The patient has a history of hypertension and long standing persistent atrial fibrillation and has shortness of breath and palpitations when in atrial fibrillation. The atrial fibrillation has been refractory to an antiarrhythmic drug (AAD) with flecainide with subsequent pulmonary vein isolation (PVI) with radiofrequency ablation (RFA). The patient had an ablation about a year ago, but has had multiple reoccurrences after ablation requiring cardioversion. The patient was referred for endoscopic surgical ablation. This was denied by the health plan and is under review.
The proposed health service or treatment endoscopy ablation (procedure to restore normal sinus rhythm) is more likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
In the last 20 years, atrial fibrillation (AF) has become one of the most important public health problems and a significant cause of increasing health care costs in western countries. The prevalence of AF is increasing due to the greater ability to treat chronic cardiac and noncardiac diseases, and the improved ability to suspect and diagnose AF. At the present time, the prevalence of AF (2%) is double that reported in the last decade. The prevalence of AF varies with age and sex. AF is present in 0.12%-0.16% of those younger than 49 years, in 3.7%-4.2% of those aged 60-70 years, and in 10%-17% of those aged 80 years or older. In addition, it occurs more frequently in males, with a male to female ratio of 1.2:1. The incidence of AF ranges between 0.21 and 0.41 per 1,000 person/years. Permanent AF occurs in approximately 50% of patients, and paroxysmal and persistent AF in 25% each. AF is frequently associated with cardiac disease and comorbidities. The most common concomitant diseases are coronary artery disease, valvular heart disease, and cardiomyopathy. The most common comorbidities are hypertension, diabetes, heart failure, chronic obstructive pulmonary disease, renal failure, stroke, and cognitive disturbance. Generally, the history of AF is long, burdened by frequent recurrences, and associated with symptoms (in two thirds of patients). Patients with AF have a five-fold and two-fold higher risk of stroke and death, respectively.
Broadly, it is classified into paroxysmal, persistent and longstanding persistent AF. Electrical, structural and autonomic remodeling are some of the diverse pathophysiological mechanisms that contribute to the persistence of AF. Treatment of AF aims to decrease the risk of stroke and improve the quality of life, by preventing recurrences (rhythm control) or controlling the heart rate during AF (rate control). In the last 20 years, catheter-based and, less frequently, surgical and hybrid ablation techniques have proven more successful compared with drug therapy in achieving rhythm control in patients with AF. However, the efficiency of ablation techniques varies greatly, being highest in paroxysmal and lowest in long-term persistent AF (as in this patient.) Treatment to prevent AF recurrences is suboptimal, particularly in patients with persistent AF. Catheter ablation is widely used for the treatment of persistent AF, but the mechanisms underlying persistent AF are complex. Recurrences of AF after ablation have been attributed to conduction gaps and nontransmural ablation lesions. Catheter ablation (CA) for long-standing persistent AF is suboptimal, and open surgical ablation, although more successful, is too invasive to be a first-line therapy. Epicardial ablation increases transmurality of ablation lesions. The limited effectiveness of endocardial catheter ablation (CA) for persistent and long-standing persistent atrial fibrillation (AF) treatment led to the development of a minimally invasive epicardial/endocardial ablation approach (Hybrid Convergent) to achieve a more comprehensive lesion set with durable transmural lesions.
The interventional treatment for long-standing persistent AF represents a major clinical challenge. It is a progressive disease, initially being nonsustained and induced by trigger activity, and progressing towards persistent AF through alteration of the atrial myocardial substrate. This patient has long-standing persistent atrial fibrillation (AF), is symptomatic, and treatment has failed. The Society of Thoracic Surgery guidelines recommend that "Surgical ablation for symptomatic AF in the absence of structural heart disease that is refractory to class I/III antiarrhythmic drugs or catheter-based therapy or both (as in this patient) is reasonable as a primary stand-alone procedure, to restore sinus rhythm. (Level of Evidence: B randomized.)" This is a Class IIa recommendation. The Society of Thoracic Surgery guidelines recommend that "Surgical ablation for symptomatic persistent or longstanding persistent AF in the absence of structural heart disease is reasonable, as a stand-alone procedure using the Cox-Maze III/IV lesion set compared with pulmonary vein isolation alone. (Level of Evidence: B nonrandomized.)" This is a Class IIa recommendation.
The proposed health service or treatment endoscopy ablation (procedure to restore normal sinus rhythm) is more likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.