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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Autonomic Nervous Function Test. The enrollee underwent autonomic nervous function testing after experiencing ongoing symptoms of dizziness, chest pain, dyspnea, tachycardia, near syncope and burning/tingling sensations.  The documentation indicated she initially underwent a cardiac consultation complaining of three episodes of pre-syncope.  The documentation detailed the enrollee has seen a pulmonologist and pulmonary function testing did not identify a reason for this.  She has also seen gastroenterology and endocrinology.  The physical examination did not reveal any significant abnormalities.  The patient's laboratory studies were normal.  An ECG showed normal sinus rhythm.  The recommendation was made for the patient to undergo additional testing to include an echocardiogram, as well as a Holter monitor and autonomic reflex screening to rule out dysautonomia.  Testing revealed an ejection fraction of 55 to 60%.  She had a good exercise tolerance and the tilt table testing revealed mild generalized autonomic impairment within the adrenal genic system.  The tachycardia response was in excess of the blood pressure drop, which was consistent with postural orthostatic tachycardia syndrome.According to the medical literature, postural tachycardia syndrome (POTS) is defined by a heart rate increment of 30 beats/min or more within 10 minutes of standing or head-up tilt in the absence of orthostatic hypotension. The standing heart rate is often 120 beats/min or higher. The documentation detailed the enrollee was being evaluated for autonomic nervous dysfunction for which autonomic nervous function testing was performed.  The requested testing is considered appropriate in combination with tilt table testing given the need to monitor the bodys different responses to be able to diagnose the patient with conditions such as postural orthostatic tachycardia syndrome.  This enrollee has had a history of dizziness and presyncope for more than ten years.  When she has these episodes, she sometimes experiences shortness of breath, palpitations and gastrointestinal symptoms. Some orthostatic changes have been noted.  The enrollee underwent autonomic nervous function test, which allowed physicians to have quantitative data to follow her progress with different treatments.  The fact that this testing allows guidance of therapy, which in this case did lead to improvement of her symptoms, proves its value.  Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is overturned.Credentials/Qualifications: Three reviewers are board certified in Cardiology. All are actively practicing.  All three reviewers are experts 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.