Impact of prospective peer review on pacemaker implantation rates in Massachusetts

Preapproval of elective permanent pacemaker insertions in Medicare patients is now mandatory for reimbursement. Of 1,860 requests for approval of an initial pacemaker implant in Massachusetts, 1,494 (80.3%) met strict Medicare guidelines and were approved by a nurse reviewer, and 366 (19.7%) were referred to an independent physician because of a question of appropriateness of indication or type of pacemaker. Only five requests (0.27%) were denied because of an inappropriate indication for pacing. On a second review of these records, an additional eight pacemaker insertions (0.43%) were deemed to have been inappropriately approved. Comparison of the annualized number of pacemaker requests for the study period with those of the 3 years before mandatory approval revealed a reduction of only 3.7%. Thus, contrary to previous findings in other areas of the country, in Massachusetts, inappropriate pacemaker insertions are rare and the effect of the prior approval process is minimal.