Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations
Treatment: mobile cardiac outpatient telemetry (MCOT)
The insurer denied mobile cardiac outpatient telemetry (MCOT).
The determination is upheld.

This is a female patient who was evaluated for palpitations and "pinching" chest pain. Her palpitations were described as "rare" and lasting a few seconds. Her electrocardiogram showed sinus rhythm with a rightward axis and nonspecific T wave abnormalities. An echocardiogram showed normal left ventricular size and function and no significant valve disease. An exercise treadmill test showed no evidence of ischemia. The patient wore an ambulatory cardiac monitor with mobile cardiac outpatient telemetry (MCOT). This showed no significant arrhythmias. Her rhythm during these episodes was sinus with rates ranging from 54-89 beats/minute. There were 20 auto-triggered events; all showed sinus rhythm/tachycardia/bradycardia with rates from 46-169 beats/minute. The medical necessity for the mobile cardiac outpatient telemetry (MCOT) is at issue.
Based on the documentation provided mobile cardiac outpatient telemetry (MCOT) was not medically necessary.
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 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. 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 some 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 was capable of continuously monitoring the patient's rhythm and immediately transmitting any detected abnormal rhythm, or patient-triggered event, to a remote station that is manned by technicians at all times. They have the advantage of facilitating prompt physician notification and intervention in the event of a potentially serious arrhythmia. For this reason, they 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 crypotogenic 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 atrial fibrillation.