Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Arrhythmia/Irregular Heart Rhythm
Treatment: Introduction of Subcutaneous Cardiac Rhythm Monitor
The health plan denied the requested service of Introduction of Subcutaneous Cardiac Rhythm Monitor as not medically necessary. 
The health plan determination is overturned.

The patient is a man with pulmonary and cardiac sarcoidosis. He underwent two catheter ablation procedures for atrial fibrillation. He had atrial tachycardia and underwent implantation of a LINQ implantable loop recorder (ILR). He was started on Dronedarone and later Propafenone after subsequent recurrences. His cardiac sarcoidosis was first diagnosed when he was found to have nonsustained ventricular tachycardia. Cardiac positron emission tomography (PET)/magnetic resonance imaging (MRI) showed active inflammation that was treated with immunosuppression. His left ventricular ejection fraction was normal. The ILR reached the end of its battery life recently.
Coverage for removal of the previously implanted ILR and implantation of a new device is at issue for medical necessity.

I overturn, in whole, the health plan's determination that this service, in this instance, is not medically necessary.

Based on the documentation provided, implantation of the subcutaneous cardiac rhythm monitor is medically necessary.
This patient has a history of cardiac sarcoidosis, atrial fibrillation and nonsustained ventricular tachycardia. Cardiac sarcoidosis is associated with both atrial and ventricular arrhythmias, as well as with conduction system disturbances, including heart block. Patients with cardiac sarcoidosis are at increased risk for sudden cardiac death. In those with normal left ventricular ejection fractions and without a history of sustained ventricular arrhythmias, risk stratification and decision making regarding appropriate therapy can be challenging. Particularly given the episodic nature of many arrhythmias, conventional external ambulatory electrocardiographic monitoring is of limited utility. However, long-term arrhythmia monitoring with an implantable loop recorder (ILR) has been shown to enable early detection of clinically important arrhythmias, even in low risk, asymptomatic individuals with cardiac sarcoidosis. Such detection can allow for early intervention, such as immunosuppressant therapy and/or pacemaker or defibrillator implantation. Moreover, continued monitoring with an ILR in this instance would be useful in detecting recurrent atrial arrhythmias in this man who has undergone two catheter ablations for atrial fibrillation. Continuous monitoring via an ILR in this situation has proven superior to intermittent external monitoring and allows for more nuanced decisions regarding anticoagulation, antiarrhythmic drug therapy and repeat ablation procedures.
Per the definition provided a medically necessary service is:
* Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective; (MET).
* Required for the direct care and treatment or management of the condition; (MET).
* Provided in accordance with generally accepted standards of medical practice; (MET).
* Not primarily for reasons of convenience; (MET).
* Not more costly than an alternative service that is likely to produce equivalent results. (NA; no alternative service is likely to produce equivalent results).