Diagnosis: Atrial Fibrillation
Treatment: Cardiac Event Monitoring [heart monitor that is implanted under the skin]
The insurer denied Cardiac Event Monitoring [heart monitor that is implanted under the skin]
The determination is upheld.

The patient has hyperlipidemia, hypertension (HTN), atherosclerotic cardiovascular disease (ASCVD), mild carotid stenosis and adenocarcinoma of the right lung. He underwent thoracic surgery and was noted to have atrial fibrillation post-operatively. A Ziopatch was done showing a low atrial fibrillation (AF) burden. He was prescribed Eliquis.
He underwent stress testing and developed atrial fibrillation at the end of exercise. Most recently, he reports episodes of "brain scrambles" and near syncope, felt to possibly be arrhythmia-related. He reported heart rates in the 180s noted on his Apple watch, associated with brief palpitations during these episodes.
Insertion of a loop recorder (ILR) was recommended and is under review for medical necessity.

The requested service of ILR (implantable loop recorder ) monitoring is not medically necessary. This patient has known paroxysmal atrial fibrillation, diagnosed one year ago, and recently has symptoms of dizziness and difficulty focusing, which may be related to atrial fibrillation. While correlation of his symptoms with arrhythmia is important, insertion of a loop recorder is not indicated as the initial step in detection. External event monitoring has not been performed to assess his most recent symptoms.
ILR is indicated for suspected AF in the setting of cryptogenic stroke, and Holter monitor or other noninvasive cardiac monitor is contraindicated, or results unrevealing or indeterminate, and recurrent paroxysmal atrial fibrillation is suspected, and test results may impact patient management, per Milliman Guidelines for ILR.
The patient does not meet standard guidelines for ILR. He did not have at least 3 weeks of external event monitoring. While he did have event monitoring with a Ziopatch, this was prior to the current symptom onset.
Therefore, the requested service is not medically necessary.