Arrhythmia/Irregular Heart Rhythm denials at external review

• the question matters

  The outcome turns on which question was put to the reviewer: 48.5% on medical necessity (n=33) against 34.3% on experimental/investigational (n=35) — a gap of 14 points inside the same condition.

California requires each published decision to carry “a detailed case summary that includes the specific standards, criteria, and medical and scientific evidence, if any, that led to the case decision” (Health & Safety Code § 1374.33(h)(1)(K)). These are the elements our extraction found in this class, split by how the decision came out.

Read as description, not instruction. These are patterns in what reviewers wrote, not steps to follow, and no combination of them predicts an outcome. Only codes that cleared the validation gate appear — thirteen did not.

• American College of Cardiology—4
• American Heart Association—4
• FDA—2

A rate here is the outcome of decisions that named the authority, not the effect of naming it. Reviewers cite the standard they applied; the citation and the outcome share a cause.

• Cardiovascular procedures—27
• Diagnostic imaging & screening—26
• Pharmacy—7
• Durable medical equipment—5
• Acute inpatient medical—1
• Diagnostic & physician evaluation—1
• Emergency & urgent care—1
• Skilled nursing & inpatient rehab—1

Browse all treatment classes · Pick your own pair

• Heart Monitor—15
• Other—13
• Surgery—10
• Cardiac Rx—4
• CT Scan—3
• Pacemaker/Defib—3
• Vein Ablation—3
• Wearable Cardio Defib—3

• Experimental/Investigational34.3%35
• Medical Necessity48.5%33
• Urgent Care—1

Medical-necessity review asks whether the care is needed. Experimental/investigational review asks whether it is likely to be more beneficial than standard therapy — a harder statutory test, and the rates show it.