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

Physician 1: The patient is a 50-year-old male who was recently evaluated for alcoholic cardiomyopathy.  His cardiac workup revealed a normal electrocardiogram (EKG) and an impedance cardiography (ICG), which was positive for hypertension. The Health Plan has denied reimbursement for the ICG on the basis that it is considered investigational for evaluation of hypertension.The patient has hypertension JNC stage III, treated with one medication, Toprol XL-50 mgm. Review of the relevant scientific data reveals that there is no body of peer-reviewed literature to substantiate the effectiveness of ICG in the management of hypertension. The use of ICG in this clinical setting was without clinical value and was unnecessary. Therefore, I have determined that the procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 50-year-old male who is on a single drug, Toprol, for hypertension. He has undergone impedance cardiography (ICG) on an outpatient basis. It is unclear if the patient has cardiomyopathy or symptoms suggestive of cardiomyopathy. The patient has requested reimbursement for the ICG. The Health Plan has denied this request on the basis that the efficacy of ICG has not been established.ICG for cardiac outpatients has variable acceptance in the following circumstances: differentiation of cardiogenic from pulmonary causes of acute dyspnea, optimization of atrioventricular interval, CHF monitoring, transplant medicine or drug resistant hypertension. However, ICG is not considered standard of care in managing hypertension. It is not recommended in JNC 7 or other guidelines for routine management of hypertension. Rather, targeted therapy such as ace inhibitors and beta-blockers (if the patient has a cardiomyopathy) is instead recommended. In this particular case, the patient is on a single agent without evidence of medical resistance or resistant hypertension. According to the Centers for Medicaid and Medicare Services, ICG is not to be used in compensated CHF, compensated cardiomyopathy or hypertension.Based upon the information set forth above, I have determined that the procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 50-year-old male with alcoholic cardiomyopathy, headaches and hearing loss. He also has hypertension. The patient underwent impedance cardiography (ICG) to diagnosis and aid in management of his condition. At issue is whether ICG was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Based on the information provided and a literature review, there is no evidence to demonstrate improved outcomes with ICG in treating outpatient hypertension compared to standard available therapy. The procedure at issue remains investigational for this indication at this time. Accordingly, I have determined that the procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.