No Longer Living in Denials

I received this notice, dated 1 March 2012, from our billing department after a denial for reimbursement following a successful right ventricular outflow tract ablation I performed:

"Paul Rossi DO, a Cigna Medical Director, reviewed Use of an intracardiac electrophysiological 3-dimensional mapping system in the diagnosis, treatment, or management of ventricular arrhythmias or any other condition because there is insufficient scientific evidence to support use and determined the service(s) is not a covered benefit as indicated below:

Service referenced: Electrophysiological 3-Dimensional Mapping and Catheter, electrophysiology, diagnostic/ablation, 3D or vector mapping

The use of an intracardiac electrophysiological 3- dimensional mapping system is considered medically necessary when used to guide supraventricular arrhthmias.  Based upon current available information, coverage cannot be approved to support the use of intracardiac electrophysiological 3-dimensional mapping in the diagnosis, treatment, or management of ventricular arrhythmias or any other condition because there is insufficient evidence to support its use.  At the present time, it is considered non-standard testing and falls under the category of experimental/investigational/unproven."

These denials are part of life for doctors - it's all part of the game.  But the era of social media is upon us, and with it, revenge.

We should first ask ourselves if Paul Rossi, DO, whose google search reveals he was an emergency room doctor working in "preventative medicine,"  should have ability to determine what constitutes standards of care in the field of cardiac electrophysiology when he, himself, is not credentialed in this subspecialty. 

But that's not all.

Even Cigna's own recently published "guidelines" for approval state:

The CARTO® EP Navigation System (Biosense Webster, Inc., Diamond Bar, CA) received 510(k) premarket approval in December 1999 by the U.S. Food and Drug Administration (FDA) as a Class II device for catheter-based cardiac mapping (FDA, 1999). The FDA indications for use state the intended use of the CARTO EP Navigation System is catheter-based cardiac mapping. The CARTO EP Navigation System and accessories have had numerous enhancements with the latest device, the CARTO 3 Version 1.05 EP Navigation System and accessories, receiving 510(k) premarket approval in 2009 (FDA, 2009; FDA, 2006; FDA, 2000).

Hardly experimental.

Furthermore, those same recommendations detail at least 8 different studies where 3-dimensional mapping was used for VT ablation and include this statement from the Joint Heart Rhythm Society/American College of Cardiology guidelines for ablation (2006):

"Electroanatomic magnetic mapping capabilities are being applied to aid in the diagnosis and nonpharmacological treatment of arrhythmias. The authors state, 'although not yet established as requisite or "core" equipment for the EP laboratory, these and other emerging technologies have had, and will continue to have, a major impact on the practice of cardiac arrhythmia management.'"

I'm sorry, but I do not see the words "experimental" in Cigna's own documentation nor does their document suggest that appropriate standard of care for 3D mapping be reserved exclusively for "supraventricular" arrhythmias.

Welcome to the world of social media, Cigna.  I can only hope that every employee out there with an option to choose insurers strongly consider picking another insurance carrier since they will be much better (and more safely) served when they need their ventricular tachycardia successfully ablated.  Rest assured, my response to Dr. Rossi's coverage denial decision is forthcoming.

Thanks so much for wasting my time.

-Wes