Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for CT heart calcium scoring scan without contrast (CPT code 75571). She saw her cardiologist for follow up of premature atrial contractions (PACs). Her atherosclerotic cardiovascular disease (ASCVD) risk was 9.8%. The cardiologist ordered computed tomography (CT) heart calcium scoring without contrast (CPT code 75571). The total coronary artery calcium scoring was 17, placing the enrollee at the 30th percentile for asymptomatic females of this age. According to the medical literature, Framingham risk score (FRS) of 10-year atherosclerotic cardiovascular disease (ASCVD) risk less than 10% is considered low risk. However, studies have shown the predictive power of cardiovascular risk factors decreases with age, partly because of selective survival and the influence of co-morbidities on risk factor levels. Because calcification of the coronary arteries can be seen as a cumulative measure of lifetime exposure to cardiovascular risk factors, coronary calcification may be especially important for assessing cardiovascular risk in the elderly. The medical literature indicates coronary calcification was found to be a strong and independent predictor of coronary heart disease for elderly patients, ages older than 70 years old; and is recommended to improve prediction of coronary events for this vulnerable age population. This enrollee is 72 years old. The records indicate the enrollee has a family history of early coronary arteriosclerosis, and is thus, at a higher risk for a cardiovascular event, despite her borderline to intermediate risk (9.8%). As per a study on coronary artery calcium (CAC), scoring in low risk patients with family history of coronary heart disease, low risk patients with a family history of coronary heart disease who have CAC greater than 100 were associated with increased risk of all cause and coronary heart disease (CHD) mortality with event rates in a range that may benefit from preventive pharmacotherapy. Since a CAC score of 0 has been associated with low risk of CHD, even in the presence of traditional cardiovascular risk factors, guidelines on the treatment of blood cholesterol recommend utilizing CAC scoring in patients at borderline to intermediate risk (5-20% 10-year ASCVD risk) in which statin therapy decisions are uncertain. Statin medication is recommended for patients with 10-year ASCVD risks of greater than or equal to 7.5%. The medical literature shows there is still a question about when the CT heart calcium scoring scan is most effective. It appears to be most useful when the enrollees risk score is intermediate and not very low. This enrollees risk score of 9.8% puts her in a category that allows for further discussion about enrollee management. The major indication for using the CT heart calcium scoring scan in this case is the fact that the enrollee was resistant to taking a statin medication. The results of the test in this enrollee allowed her physician to have a discussion about the degree of risk the enrollee had and to encourage her to take a statin medication. For this reason, this scan is more beneficial for this enrollee when compared with other standard treatments since this test does not pose any risk. Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Cardiovascular Disease and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.