Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage a standing computed tomography (CT) scan. Bernasconi and colleagues state, Over the last years, an increased number of studies have reported the use of cone beam weightbearing computed tomography (WBCT) in the assessment of foot and ankle pathology. This new technology has enabled to overcome the limits inherently related to two-dimensional radiographs (superimposition bias, operator-related bias, rotation bias) and to obtain images reproducing the bones and joints anatomy during physiological standing with a low radiation dose. Godoy-Santos and colleagues state, Cone-beam computed tomography (CBCT) has been applied in dentistry and medicine for nearly two decades. Its application in the foot and ankle specialty has grown exponentially in recent years. Weight-bearing CBCT allows clinicians to obtain weight-bearing images that can be viewed in all three planes and to construct three-dimensional models, similar to those constructed from traditional CT scans, as well as exposing patients to less radiation than do traditional CT scans. This technology has revolutionized diagnoses, improving the understanding of various lesions and surgical planning in the foot and ankle specialty. Ongoing studies of the use of weight-bearing CBCT in foot and ankle surgery are focused on fully automated and semi-automated three-dimensional measurements, as well as bone segmentation, mapping of the distances/orientation of the joints, and the production of customized implants. Conti and colleagues state, WBCT scans of the foot and ankle have improved the understanding of deformities that are not easily identified on radiographs and are increasingly being used by orthopedic surgeons for diagnostic and preoperative planning purposes. In contrast to standard CT scans, WBCT scans better demonstrate the true orientation of the bones and joints during loading. They have been especially useful in investigating the alignment of complex pathologies such as adult-acquired flatfoot deformity in which patients have been found to have a more valgus subtalar joint alignment than in a normal cohort and high rates of subfibular impingement. Studies using WBCT scans have also provided new insight into more common lower extremity conditions such as hallux valgus, ankle fractures, and lateral ankle instability. WBCT scans have allowed researchers to investigate pronation of the first metatarsal in patients with hallux valgus compared with normal feet, and patients with lateral ankle instability have been found to have more heel varus than healthy control subjects. Understanding the application of WBCT scans to clinical practice is becoming more important as surgeons strive for improved outcomes in the treatment of complicated foot and ankle disorders.In this case, the patient reports chronic pain in the left ankle and presented with posterior medial ankle pain. The patient reports difficulty walking and pain with ambulation. An MRI demonstrated 2 cm high-grade interstitial partial-thickness tear of the posterior tibialis centered around the medial malleolus; severe, diffuse posterior tibialis tendinosis with moderate tenosynovitis and tendonitis; moderate stress response of the distal posteromedial tibia deep affecting the posterior tibialis tendon groove; moderate pes cavovarus; moderate osteoarthritis of the second and third tarsometatarsal joints; mild Achilles tendinosis; mild plantar fasciitis; moderate subcutaneous edema of the medial ankle. However, despite being requested, the submitted documentation did not show the trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures including the failure of physical therapy or home exercises. Given that the requested service appears relatively redundant to available imaging, the requested service is not medically indicated. Therefore, a standing CT scan is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert 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.