Qualifications for PVI

[StefJarrell]

Good morning - I have been suffering from afib for about 5 years.  In the past 5 months my antiarrythmic meds stopped working.  Since Aug 25, 2005, I have been to the ER 9 times, for 7 cardioversions, and have been hospitalized once to switch medications.

I have poor to non-existent rate control from medication while in afib, and jump around from the 120s to the 170s.  I have had a couple episodes of aflutter and sinus tach.  Because of my poor rate control, and my suddenly frequent events (6 in the past two months and 1 since medication switch) my cardio recommended a PVI ablation.  I was scheduled to have the surgery this tuesday.  Last Wednesday my insurance company decided to decline coverage based on the fact that I did not meet the "medical necessity criteria require for cathedar ablation of arrhythmogenic foci in the pulmonary veins as a treatment of atrial fibrillation."  !!!!  

I'm floored by this decision, and am looking for any recent documentation of the efficacy of PVI for treating afib.  If you could point me toward medical reviews or publications that would be great.  If you have any other advice on how I might proceed, I'm all ears.  We will go through formal appeal, but I want to make sure I have all my ducks in a row before that, since I feel I don't have alot of time to spare.  If you think a second opinion from Cleveland would be weighty in this fight, I'm all for that as well.

I appreciate any references or guidance.  

thanks

SJ

[CCF-M.D.-MJM]

HI SJ,

I am sorry hear about your poor rate control.  That must be very frustrating.

The best advice I can give to find a good doctor that is willing to appeal to the insurance company.  I think you will have a very difficult time fighting it and a physician may have better luck.  We do over 100 PVAI's a month and I have never heard of anyone being turned down for insurance reasons before.

If you are able to come to Cleveland for an opinion, make sure your doctor forwards all your holter records, some EKGs, echo, stress test and cath if you have had one.  It is probably best if you bring a copy of the records with you incase they get lost.

In the mean time, there are many medications you could try unless you have contraindications -- sotalol, amiodarone, Tikosyn, rhythmol, flecainide in addition to a beta blocker and/or calcium channel blocker.

You insurance company may want you to have an AV nodal ablation and pacemaker.  This may be a decent opition if you are older and have a lot of other medical problems.  If you are relatively young and otherwise healthy, a pacemaker is probably not the best option.

If you want to come to Cleveland, call soon.  There is sometimes a long wait for appointments.  I think having a good advocating physician is your best option to force your insurance company's hand.  We actually have a team of nurses in our AF center that takes care of this and are pretty successful.

One more word to the wise, make sure you know how many PVIs your doctor has done.  I have stories recently of physicians doing between 2-10 of these precedures or some cases just observing someone else doing it before they start doing it on there own.  Somewhere around 100 procedures is when you really start feeling comfortable doing PVAIs.

I hope this helps and thanks for posting.

[Lyn2]

Wow!  I can imagine that you are floored.  I can relate.  I have had paroxymal a-fib and multiple focal atrial arrythmias for the last few years.  Last week I finally had an av node ablation.  My doc. said a PVI would not work for me as there are so many other foci, it just jumps from one rhythm to the next.  I have been on all the anti-arrythmics, and was at the end of the list.  I really can't believe that you don't qualify for this procedure.  That is just absurd.  It's not as if this was a one time event for you.  I am now 100% dependant on a pacemaker, but it sure feels better than having my rate all over the place 24/7.
I wish you luck!  Definately pursue the appeal, and have your doc. write a letter.  That often works!

[StefJarrell]

thanks to you both.. just to clarify, I am just 42 and have already gone through Verapamil, Cardizem, Sotolol, Tikosyn (kept me in NSR for 15 months straight.. yea!) and now am on Rhythmol and Atenelol.  I am certainly willing to try flecenide, but am not, at this point, willing to go on amiodarone...  I am also willing to have a mini-maze, which absurdly my insurance would probably cover, or a full maze for that!  My insurer is one of the "biggies" and the one people usually pay the most for JUST so they don't have to deal with hassles... another reason this is so puzzling!

I was to have the procedure at Johns Hopkins by Dr. Hugh Calkins, so it wasn't like I was going to an unknown.  Dr. Calkins has many hundred PVIs under his belt.

My own cardio, who has recommended this procedure, will be my champion, as well the consultants my law firm hires specifically to mediate these things.  Interestingly enough, the claim was reviewed and rejected by a doctor who is trained in internal medicine and emergency medicine... what every happened to cardios revieweing cardio cases?

SJ

[Lyn2]

SJ,
I am in my mid 30s, so I understand what you are feeling.  I was on Amiodarone for 5yrs.  It was the only thing that worked to control my rhythm.  Never completely, but better than all the others.  Tikyson caused a serious rhythm problem.  Thank God I was in the hospital when they initiated it, and my last antiarrythmic was flecanide and cardizem.  At the point I went off amiodarone and onto those, my rhythm became completely chaotic.  
I wonder if your insurance company considers the PVI ablation as still experimental.  Hmmm.  I think the doc. is right.  Get your docs. on it.  They will have a much better chance, but it sounds like you already are.
Good luck, and keep us posted!
cn

[dquenzer]

I can't believe an insurance company not paying for it.  I had a PVI ablation at Mayo two years ago, and my insurance company paid all but 3500.  The total cost was 55,000. That didn't include my motel stays, travel, etc.

My PVI worked wonderfully.  Not only cured the AFIB, but also some flutter, and PAC issues.  There was only one foci that caused PAC's they couldn't get, but that was minimal.  Even checked for PVC's.

I would definitely keep fighting the system.  The problem is that you just can't switch insurance companies.  The fact that drugs do not keep you in rythmn and you are symptomatic has got to be a big issue.  Get the doc involved.  I'd even consider taking them to court or some kind of arbitration.

Good luck!

[CCF-M.D.-MJM]

It sounds like the new AFib guideslines are set for release in several months.  They will make atrial fibrillatios ablations (PVIs, PVAIs) second line after a trial of medical therapy.  This guideline change will make it more difficult for insurance companies to decline atrial fibrillation ablations.

[PikaPika88]

Do you really need to go to ER for every A-Fib?  What are the Drs going to do?  

I went to ER once.  They're just looking at the monitor and see how tricky my pacer is.  They ran a blood test and x-ray.  No IV, not even can find a 50mg flecainide for my night dose. Put me in the hospital for a 24 hours full monitoring and waited 2 days for a technician to come and check my rhythm.  After that go home and take 50mg flecainide twice a day like usual.  Dr asked, "when was the flecainide not working?"  I told her 2 months ago.  Discharge medication still remain unchanged. Pacer program remain unchanged.  ???  very confused!  Do you think I'm still going to take it?  See the not working medicine "How much fun!"

Pika.

[Theresau]

Have you tried supplementation to either alleviate or lessen your symptoms?

I too have been in constant/persistent afib for 3 years now and have a high heart rate as well.  I went on Tikosyn mid Jan/2006 (at CCF) and was then electrically cardioverted and then went back into afib (with a huge bang) 5 days later.  I then was cardioverted the 7th day and went back in 36 hours later.

I'm going back to CCF next week to give the electrical cardioversion one more try.

However, I have found that taking magnesium and keeping my potassium up by eating a high potassium diet really helps my symptoms.  I'll still be in afib but my heart rate is better and the afib feels less chaotic.  I take around 1000mg of Metagenics magnesium glycinate.

I also take Coreg but have seen very little effect from it other than if I get into a very strong afib attack - appears to then help some with the heart rate.  But on a daily basis, I've found very little effect from taking the Coreg.  

I was on amiodarone for 6 months - went out of afib for less than a week but then it became much worse.  Same thing happened with digoxin.

I've had problems (and found no effect either) with Toprol XL and Metropolol as I frequently have bronchitis.  Coreg gave me grief too - I had to start with a very small dose and then take months to increase it.

I also have a transmitter for transmitting an EKG to CCF - find this very helpful as when the afib gets very chaotic, I can't get a good pulse read.

Just thought I'd mention this so you don't feel alone.  I'm scheduled for a PVI ablation at CCF but the appt. is sometime away.  I did check with my insurance co. and they indicated I was covered.

Have you ever been on the www.afibbers.com site (LAF Forum).  The posters on that site are very knowledgeable and very helpful.

Theresa

[Theresau]

One more comment - I've been very happy with CCF.  It's great to work with a team that understand AF.  Even the secretary there understands.  The nurses are great.

The word about AF has been spread well throughout the cardio world there as well - I could discuss it even in the cardio labs.

My cardiologist is at University of Michigan but I plan to continue to be followed by CCF for EP.  (He is aware of such.)  I was originally hospitalized at UofM and it appeared to me that their forte was CAD.  They have a great EP but to my knowledge there is no "team/clinic" as there is at CCF.

Theresa