Administrative Memos

200406

FROM: Theodore O. Will, Chief Executive Officer
DATE: Aug 13, 2004
SUBJECT: Automatic Implantable Cardioverter Defibrillator (AICD) Project Baseline Report
IPRO CONTACTS:

Kathy Terry, Ph.D., Sr. Director, Medicare/Federal Health Care Assessment at 516-326-7767, Ext. 226, Monty Bodenheimer, M.D., Medical Director, Medicare/Federal Health Care Assessment at 516 326-7767, Ext. 539

The attached report details the results of IPRO's study to determine the appropriateness of Automatic Implantable Cardioverter Defibrillator (AICD) implantations for Medicare beneficiaries in New York State (NYS). In conducting the review, IPRO used the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines that define the clinical indications for AICD use. In addition, the Medicare National Coverage Guidelines for AICD insertion define the clinical indications that must be present for Medicare to cover payment.

As part of the study, a tool was developed to screen for inappropriate use of an AICD. Electrophysiologists reviewed all cases not approved by the tool. If concerns remained, a preliminary inquiry was issued and comments were solicited from the implanting physician. The case was reassessed after receipt of the response. The enclosed report (Attachment A) reflects the final determinations after completion of the review process. You are encouraged to review this report carefully.

In brief, fully 16% (46/296) of all reviewed cases resulted in a denial. It is important to recognize that 35% of all denials did not involve Medicare coverage issues but rather involved significant clinical quality issues. These cases represent an area of concern for patients, physicians and hospitals and, certainly require additional discussion, with both physician and hospital review of these data. The remaining 65% of the denials involved Medicare coverage issues. While a portion of these denials would be approved had the procedure date occurred after October 1, 2003, there are a greater number of cases that would remain as denials today. These coverage denials point to the need for physician and hospital review and understanding of coverage guidelines prior to AICD insertion and billing to Medicare.

To facilitate hospital and physician understanding of the data, IPRO will be conducting two AICD Webinar trainings. Dr. Monty Bodenheimer, Medical Director, Medicare/Federal Health Care Assessment will conduct the first call on September 14, 2004 at 8:00 a.m. This call is directed to physicians involved in the decision-making process and implantation of an AICD. The program will review the results of the study and areas for improvement using case examples to highlight both clinical issues and coverage guidelines. The second call, which is scheduled for September 21, 2004 at 10:00 a.m., will review the AICD screening tool in detail to provide hospital staff with an opportunity to observe the tool in action and to understand how the tool may be used at the hospital. Each program is scheduled to run for 90 minutes.

Hospitals and physicians must register to participate in each of these trainings. Participants will need access to both the Internet and a telephone line for participation in these trainings. Attachment B provides detailed registration instructions. Registration is also available at https://ifmcevents.webex.com. We request your assistance in keeping slots open for all hospitals and physicians wishing to participate by encouraging staff within your facility to share the computer/telephone line used for the training event, whenever possible. In addition, IPRO will make an on-line recording of the trainings available at http://www.ipro.org/hpmp.

Attachment C provides a hospital-specific report, if your hospital had cases selected for review. We have also included an AICD project CD created by IPRO, which includes the computerized AICD screening tool, a MS Word document tool with instructions, installation instructions, and more.

Physicians and hospitals are encouraged to:

Review the full project report;
Examine their hospital-specific data, where applicable;
Register and participate in the Webinar conference calls;
Download and install the AICD project CD;
Review the denied case examples provided; and
Incorporate the AICD screening tool in their utilization management efforts.

The next phase of the AICD Project will continue after the Webinar calls are complete. Following a period of time to allow hospitals an opportunity to monitor and reduce inappropriate AICD insertions, IPRO will select a random sample of discharges for review. The AICD screening tool will again be used with full case review ensuing should a case fail IPRO's AICD pre-screen. Analysis will be performed on these data and appropriate baseline comparisons will be made. These results will be disseminated to the hospitals along with any additional general recommendations and hospital specific required actions, should changes in practice not be evident.

Should you have any questions or comments about this memorandum and/or the training please contact Dr. Kathy Terry, Ph.D., Sr. Director, Medicare/Federal Health Care Assessment at 516-326-7767, extension 226, or Monty Bodenheimer, M.D., Medical Director, Medicare/ Federal Health Care Assessment at 516 326-7767, extension 539.