Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the Cardiac contractility modulation (CCM)
system
You asked the Plan to pre-approve Cardiac contractility modulation (CCM) system. You say this system is
medically necessary for the enrollee. The Plan denied your request. The Plan says medical necessity had not
been established. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional
information.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Cardiac
contractility modulation (CCM) system. MAXIMUS determined that the plan had not made reasonable and
diligent efforts to gather and forward information regarding their decision to deny the request. Additional
information was requested from the Plan because the case file was received with missing pages and incomplete.
The Plan did not send the requested documentation. Therefore, it was decided that the Plan had to provide
coverage for a Cardiac contractility modulation (CCM) system (0408T) for the enrollee.
The Plan requested a reopen and submitted additional information and medical records. The Plan feels that the
denial of the CCM was appropriate, given the clinical scenario. The medical records show the enrollee is a 72-
year-old man with a history of coronary artery disease, cardiomyopathy, and chronic heart failure with a
reduced ejection fraction (20-25%). It was determined that the enrollee was a candidate for primary prevention
ICD or a CCM device. The enrollee was admitted to the hospital from August 5, 2021, to August 7, 2021, with
a CHF exacerbation. On August 30, 2021, it is documented in the Advanced Heart Failure and Transplant
Cardiology Outpatient Follow Up Note, that the enrollee's Entresto and Torsemide were increased, and that he
was feeling much better and is considered "Class 1 now." We decided that the Plan does not have to provide coverage for the Cardiac contractility modulation (CCM)
system
You asked the Plan to pre-approve Cardiac contractility modulation (CCM) system. You say this system is
medically necessary for the enrollee. The Plan denied your request. The Plan says medical necessity had not
been established. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional
information.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Cardiac
contractility modulation (CCM) system. MAXIMUS determined that the plan had not made reasonable and
diligent efforts to gather and forward information regarding their decision to deny the request. Additional
information was requested from the Plan because the case file was received with missing pages and incomplete.
The Plan did not send the requested documentation. Therefore, it was decided that the Plan had to provide
coverage for a Cardiac contractility modulation (CCM) system (0408T) for the enrollee.
The Plan requested a reopen and submitted additional information and medical records. The Plan feels that the
denial of the CCM was appropriate, given the clinical scenario. The medical records show the enrollee is a 72-
year-old man with a history of coronary artery disease, cardiomyopathy, and chronic heart failure with a
reduced ejection fraction (20-25%). It was determined that the enrollee was a candidate for primary prevention
ICD or a CCM device. The enrollee was admitted to the hospital from August 5, 2021, to August 7, 2021, with
a CHF exacerbation. On August 30, 2021, it is documented in the Advanced Heart Failure and Transplant
Cardiology Outpatient Follow Up Note, that the enrollee's Entresto and Torsemide were increased, and that he
was feeling much better and is considered "Class 1 now."We decided that the Plan does not have to provide coverage for the Cardiac contractility modulation (CCM)
system
You asked the Plan to pre-approve Cardiac contractility modulation (CCM) system. You say this system is
medically necessary for the enrollee. The Plan denied your request. The Plan says medical necessity had not
been established. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional
information.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Cardiac
contractility modulation (CCM) system. MAXIMUS determined that the plan had not made reasonable and
diligent efforts to gather and forward information regarding their decision to deny the request. Additional
information was requested from the Plan because the case file was received with missing pages and incomplete.
The Plan did not send the requested documentation. Therefore, it was decided that the Plan had to provide
coverage for a Cardiac contractility modulation (CCM) system (0408T) for the enrollee.
The Plan requested a reopen and submitted additional information and medical records. The Plan feels that the
denial of the CCM was appropriate, given the clinical scenario. The medical records show the enrollee is a 72-
year-old man with a history of coronary artery disease, cardiomyopathy, and chronic heart failure with a
reduced ejection fraction (20-25%). It was determined that the enrollee was a candidate for primary prevention
ICD or a CCM device. The enrollee was admitted to the hospital from August 5, 2021, to August 7, 2021, with
a CHF exacerbation. On August 30, 2021, it is documented in the Advanced Heart Failure and Transplant
Cardiology Outpatient Follow Up Note, that the enrollee's Entresto and Torsemide were increased, and that he
was feeling much better and is considered "Class 1 now." The Plan is correct in this case. The information provided supports that the denial was correct in this case. The
documentation on August 30, 2021, indicates that the enrollee was feeling much better, and his heart failure
was classified as Class 1. This documentation does not support that a CCM system was medically reasonable
and necessary for the enrollee in this case at that time. Medicare coverage criteria were not met. We looked at
this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules
for coverage of Cardiac contractility modulation (CCM) system have not been met. Therefore, we decided that
the Plan does not have to pre-approve the Cardiac contractility modulation (CCM) system