Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations.

Treatment: external mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional.

The insurer denied external mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional.

The determination is upheld.

The patient has a history of hypertension, hyperlipidemia, elevated coronary artery calcium score, nonobstructive carotid arterial disease, atypical chest pain and untreated obstructive sleep apnea. His family history is remarkable for premature atherosclerotic cardiovascular disease. He was evaluated for palpitations. A 48 hour Holter monitor was unrevealing; the patient reported no symptoms while wearing the monitor. Myocardial perfusion imaging showed no evidence of ischemia. His left ventricular systolic function was normal. He was seen again at which time he reported a "fairly constant" sense of fluttering in his chest. He described listening to his heart with a stethoscope and hearing an "early beat" every three to four beats. He reported occasional brief lightheadedness but denied syncope or near syncope. An ambulatory cardiac monitor with mobile cardiac outpatient telemetry (MCOT) was then prescribed. The patient wore the monitor. The predominant rhythm was sinus with premature atrial and ventricular beats. There were atrial couplets with brief runs of atrial tachycardia and ventricular couplets. The ventricular ectopy composed less than 1% of the total beats. There was also one "short run" of atrial fibrillation. The exact duration was not specified and cannot be determined from the records provided. The patient's symptoms of palpitations and chest pain correlated with ventricular ectopy and sinus rhythm. At issue is the medical necessity of the requested cardiac monitor with mobile cardiac outpatient telemetry (MCOT).
Based on the documentation provided, the ambulatory monitoring with MCOT was not medically necessary.
This patient presented complaining of palpitations. When patients present with palpitations, lightheadedness, syncope, or other symptoms that are suspected to be caused by an arrhythmia, an attempt to document the rhythm present at the time the symptoms occur is the first step in guiding treatment. There are a number of devices with which to do this. Holter monitors, usually issued for 24-48 hours at a time, record the rhythm continuously on a tape or disc, which is later returned and analyzed. The major drawback of this technology, as was seen in this case, is the brief duration of recording. In patients with infrequent symptoms, the diagnostic yield is low. Patch-type monitors (for example, the Zio Patch) are similar to Holter monitors but can be worn for longer periods, up to 14 days. Event monitors are issued to patients for longer periods, usually 15 to 30 days. There are several types of these devices. Loop event monitors record the rhythm but do not store it for later analysis unless the patient experiences a symptom and activates the device or, in the case of most modern devices, if the rhythm meets certain prespecified criteria for rate or irregularity. Particularly with the first group, with no "autoactivation" function, asymptomatic arrhythmias are not generally detected. The mobile cardiac outpatient telemetry (MCOT) device that this patient wore is capable of continuously monitoring the patient's rhythm and immediately transmitting any detected abnormal rhythm to a remote station that is manned by technicians at all times. For patients with palpitations, syncope and near syncope, the diagnostic yield of these devices compares favorably to that of other devices. The MCOT feature allows for prompt physician notification and intervention in the event of a potentially serious arrhythmia. For this reason, monitors with MCOT may be more appropriate than other methods in high risk patients, such as those with syncope and structural heart disease. They have also been shown to have a high diagnostic yield in detecting atrial fibrillation in patients with cryptogenic stroke and in detecting recurrent atrial fibrillation in patients post-ablation. For this reason, they are sometimes preferred in these situations.
However, there is no documentation that this patient was at high risk for a potentially life-threatening arrhythmia, has had a stroke or has a history of catheter ablation for atrial fibrillation. Thus, in this situation, an ambulatory event monitor with auto-activation would be expected to be as effective as a device with MCOT in determining the etiology of this man's palpitations. The MCOT feature was not medically necessary.