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

Physician 1: The patient is a 62-year-old male who is reported to have small vessel disease, not amenable to revascularization. The cardiac catheterization describing the anatomy is not in the documentation provided. His angina is atypical, occurring at rest, but it is reported that he does not generally get chest discomfort while doing exercises. He is only on a beta-blocker for angina. He is also able to use an easy-glider for about half-an-hour a day. The patients provider has requested authorization for enhanced external counterpulsation (EECP) therapy, which has been denied by the Health Plan.The most recent American Heart Association (AHA) guidelines in 2002 list EECP as a class IIb therapy or usefulness/efficacy is less well established by evidence/opinion (Gibbons, et. al.). It was determined that although two studies found EECP to be generally well tolerated and efficacious, the guidelines do not strongly endorse/recommend it as yet. EECP is however useful in a special subset of patients commonly defined as those with: disabling angina (class III or IV) refractory to maximum medical therapy and not amenable to revascularization.In this case, the documentation provided does not demonstrate the patient meets the class III angina definition of marked limitation of ordinary physical activity. Angina occurs on walking 1-2 blocks. The pain at rest is described as atypical, and the patients lack of chest pain with exercise is inconsistent with class III angina. Additionally, the patient does not appear to be on maximum medical therapy for angina (a calcium channel blocker or nitrate). Furthermore, while the patient may have anatomy that is unrevascularizable, supporting reports such as the cardiac catheterization report have not been provided.In conclusion, the submitted documentation does not support the use of EECP in this case. The standard medical alternatives for this patient are: maximum medical therapy for angina such as a trial of additional medications, workup and treatment of atypical chest pain for non-cardiac etiologies, review of cardiac anatomy towards revascularization and optimization of other medical issues such as pain, depression and fatigue. Accordingly, 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 2: The patient is a 62-year-old male with atypical chest pain. He has risk factors for coronary artery disease (CAD). The records do not contain objective documentation of CAD. His chest pain has been refractory to conventional medical management for CAD. The provider has requested authorization for enhanced external counterpulsation (EECP) to treat atypical chest pain. The Health Plan has denied this request.EECP is an experimental treatment for angina pectoris. It is appropriate for individuals with angina pectoris that cannot be managed by conventional therapies such as medication and/or invasive treatment. There is no peer-reviewed body of literature to support the use of ECCP for atypical chest pain. Therefore, 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 3:The patient is a 62-year-old diabetic male with class II to III angina with reported chest pain at rest on medical therapy. The patients provider recommended enhanced external counterpulsation (EECP) therapy for treatment of angina. The provider states that the patient is not a candidate for surgical intervention due to small vessel disease. The Health Plan has denied coverage for EECP therapy on the basis that it is considered investigational.The patients provider states that a recent angiogram showed inoperable small vessel disease. The patient presents with refractory angina, unable to be controlled by medical therapy. The use of EECP is an appropriate treatment for patients in this subset. As per the ACC/AHA recommendation, (EECP) should only be used [in this subgroup] in patients who cannot be managed adequately by medical therapy and who are not candidates for revascularization therapies (surgical or interventional). Therefore, I have determined that the requested therapy 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.