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

Physician 1The patient is a 62-year-old male with a history of coronary artery disease and angina. He underwent coronary artery bypass grafting in 1988 and an angioplasty with cardiac stent placement in 1994. The patient reported experiencing chest pain in July 2004. An abnormal thallium scan showed midlateral wall ischemia. The patients provider recommended enhanced external counterpulsation (EECP). The Health Plan has denied authorization and coverage for EECP on the basis it is considered experimental for treatment of the patients medical condition.The patient has known coronary disease and angina. However, based on the submitted records of the stress test performed on 7/27/04, the patient is able to walk 8.03 on a Bruce Protocol without chest discomfort or ST changes and with appropriate augmentation of heart rate and blood pressure. Though ischemia was identified on the nuclear imaging portion of the exam, there is no evidence that the patients symptoms are severe (class III or IV). In fact, the stress test is evidence to the contrary. In addition, it appears from the records provided that standard medical therapy has not been maximized; nitrates have just been started and there is no record of beta-blocker use. Since no studies have demonstrated an advantage of EECP over standard medical therapy, the use of EECP is generally reserved for patients with limiting symptoms who are already on standard maximal medical therapy and are not candidates for coronary revascularization.Based upon the information set forth above, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2The patient is a 62-year-old male with coronary artery disease and angina. His cardiologist has prescribed enhanced external counterpulsation (EECP) for refractory angina. In 1988 the patient underwent coronary artery bypass graft and in 1994 he underwent percutaneous transluminal coronary angioplasty and stent placement. An occluded circumflex graft was noted. In July 2004, the patient exercised eight minutes on the Bruce Protocol to a maximum heart rate of 137 bpm. He reported slight chest tightness post exercise. Subsequently, the patient complained of continuing angina. A request for EECP was submitted with the diagnosis of class IV angina. The patient has been receiving diltiazem. The Health Plan has denied coverage for EECP on the basis it is considered investigational. The submitted records do not substantiate the diagnosis of class IV angina. The patient exercised eight minutes on the Bruce Protocol with mild symptoms post exercise; therefore, it appears he has class II angina. In addition, the records do not document aggressive medical management of angina. EECP is a treatment modality that has been shown to improve either exercise tolerance or threshold to exercise ischemia in patients refractory to surgical and/or medical management. EECP has not been demonstrated to produce a long-term benefit and is not standard of care for patients such as this patient. As such, EECP is not likely to be more beneficial for the patient than standard medical therapy. As set forth above, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3The patient is a 62-year-old male with coronary disease status post bypass in 1988, status post stent implant in June 2004 for unstable angina, with known residual circumflex disease 100% occluded, presumably not treatable by percutaneous revascularization. Following the procedure, the patient has persistent anginal symptoms, which are refractory to medical therapy. Nuclear stress test performed demonstrated mid-lateral wall ischemia. It has been recommended the patient undergo enhanced external counterpulsation (EECP). The Health Plan has denied coverage for EECP indicating it is considered investigational.This patient with coronary disease status post surgical and percutaneous revascularization attempt has continued anginal symptoms. A stress test demonstrates ischemia in the distribution of an artery not amenable to catheter-based intervention. Treatment of patients such as this patient with EECP has been shown to have benefit in relief of symptoms and improved exercise time. This is a medically accepted use of this technology and is likely to benefit the patient. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.