Appeal type: Experimental/Investigational
Decision: Overturned

Physician 1: The patient is a 63-year-old man with angina refractory to medical therapy, status post two previous bypass surgeries in 1983 and 2000. The patient was found not to be a candidate for repeat revascularization procedures by cardiac catheterization in December 2003. The patient has recurrent chest discomfort on minimal exertion (Canadian Class 3 to 4 symptoms by description). The patient underwent enhanced external counterpulsation (EECP) in 2004. The Health Plan has denied reimbursement for EECP therapy on the basis it is considered investigational.This patient presented with refractory angina that was unable to be controlled by medical therapy. The use of EECP in this setting is a well-known, clinically accepted and appropriate treatment for patients in this exact 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). Based upon the submitted information, the patient was an appropriate candidate for EECP therapy. Therefore, I have determined that the therapy at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned. Physician 2: The patient is a 63-year-old man with coronary artery disease. He had surgical coronary artery revascularization procedures in 1983 and 2000. In 2003, he developed recurrent chest pain. Coronary angiography in November 2003 demonstrated diffuse disease that was not correctable with angioplasty or cardiac surgery. The patient was treated with Altace, carvedilol and a nitroglycerine patch for angina. He was also treated with Crestor, Niaspan, Zetia, and aspirin to mitigate the progression of coronary artery disease. The patient received enhanced external counterpulsation (EECP) therapy in 2004. The Health Plan has determined EECP therapy is considered experimental for the patients condition and therefore, has denied reimbursement for the therapy.In 1999, the Health Care Financing Administration (HCFA) approved EECP as a reasonable and necessary treatment for certain Medicare beneficiaries suffering from stable angina pectoris refractory to medical/or surgical therapy. The HCFA approval allows coverage of this therapy in patients who have been diagnosed with disabling angina (Class 3 or Class 4, CCSF score or equivalent) who, in the opinion of a cardiologist or cardiothoracic surgeon, are not readily amenable to surgical intervention. The patient has submitted documentation of medical and surgical management for his angina pectoris. Standard available therapy was not effective for his Class 3 angina pectoris. As such, EECP therapy was medically appropriate for this patient.Based upon the information set forth above, I have determined that the therapy at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned. Physician 3: The patient is a 63-year-old man with known coronary artery disease who underwent two artery bypass graft procedures, one in 1983, and the other in 2000. In 2004, he had recurrent angina with minimal activity, a positive stress test, and repeat angiography showing diffuse small vessel disease not amenable to percutaneous revascularization or repeat CABG surgery.  The patient was on multiple cardiac medications including beta-blockers, ACE inhibitors, long-acting nitrate, statin, aspirin, and Plavix. Therefore, EECP was recommended and completed, with reported symptomatic improvement. The Health Plan has denied coverage for EECP therapy citing a lack of proven efficacy.Analysis and Findings:In this particular case, based on a review of the information provided the patient had already exhausted all of the standard treatment options for limiting angina including multiple cardiac medications, PCI, and CABG. Though the data for EECP is somewhat limited, available literature supports its usefulness in a portion of patients, including one randomized trial (MUST-EECP). It is in circumstances such as this where all other options have been exhausted and limiting angina continues, that a trial of EECP therapy is medically reasonable and appropriate. Therefore, I have determined that the therapy at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.