Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external mobile cardiovascular telemetry with 
electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of 
accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events 
transmitted to a remote attended surveillance center for up to 30 days; review and interpretation with report by 
a physician or other qualified health care professional (93228). 
 
You asked the Plan to pre-approve cardiac outpatient procedure. You say that the enrollee has a history of 
fainting where he will hit the ground/gravel. Wearing a monitor is important so they can tell him he needs a 
permanent pacemaker. The Plan denied your request. The Plan says records do not show that the enrollee has 
rate symptoms or that traditional monitoring has been unsuccessful in the diagnosis of his symptoms. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve cardiac outpatient procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a history of arthritis, benign prostatic hyperplasia, coronary 
artery disease, DM, hyperlipidemia, hypertension, myocardial infarction, and sinus bradycardia. He presented 
to the emergency department (ED) with chest pain, pressure and tingling in his left arm and neck, 
lightheadedness, and anorexia. The records give no history of stroke, and, per the ED records, he had no 
syncope. He was lightheaded and later notes gave a diagnosis of syncope. He was bradycardic in the 50s. He 
was evaluated and diagnosed with unstable angina and underwent a heart catheterization with stenting of two 
lesions in the right coronary artery. A carotid duplex was negative for carotid lesions. The review has 
determined that the enrollee does not have rate related symptoms or that traditional monitoring has been 
unsuccessful for the diagnosis of his symptom. The review has determined that the enrollee does not meet 
criteria for approval. The requested procedure is not medically necessary for the enrollee. 
 
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 outpatient procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an external mobile cardiovascular telemetry with electrocardiographic 
recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data 
storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote 
attended surveillance center for up to 30 days; review and interpretation with report by a physician or other 
qualified health care professional (93228).