Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Problem with the Blood Vessels that Carry Blood to the Heart
Treatment: Myocardial Perfusion Imaging (MPI)
The health plan denied the requested MPI as not medically necessary.
The health plan's determination is overturned.

The patient is a woman with a history of coronary artery disease, percutaneous coronary interventions with stents in the left anterior descending and right coronary artery, peripheral arterial disease and chronic obstructive pulmonary disease (COPD). She was evaluated for cardiology clearance prior to hip replacement surgery. Her electrocardiogram showed sinus rhythm with left ventricular hypertrophy with repolarization abnormalities. She complained of exertional dyspnea. An exercise stress testing was performed. The patient exercised for 3 minutes, 51 seconds, reaching a maximum heart rate that was 70% (percent) of her maximal predicted rate. The test was stopped due to dyspnea. She denied chest pain. There was 1-2 millimeter of horizontal ST (interval between ventricular repolarization and depolarization) segment depression in the inferior leads during exercise.

The medical necessity for myocardial perfusion imaging (MPI) is at issue.

I overturn, in whole, the health plan's determination of medical necessity.

This patient has known coronary artery disease and symptoms of exertional dyspnea, which may be an anginal equivalent. She is scheduled to undergo hip replacement surgery. Given her history, poor functional status and symptoms, preoperative testing to rule out myocardial ischemia is appropriate and in accordance with current guidelines. She has recently undergone exercise treadmill testing that revealed poor exercise tolerance and an inability to reach a diagnostic heart rate. While she did have some ST segment depression during exercise, her resting electrocardiogram showed left ventricular hypertrophy with repolarization abnormalities; these changes are known to result in false positive ST segment depression during exercise. Thus, the results of the treadmill test were equivocal and further testing is needed. Since the proposed test uses pharmacologic stress, rather than exercise stress, the results are not confounded by poor exercise tolerance and/or inability to reach a target heart rate. In addition, rather than relying on electrocardiographic changes to diagnose ischemia, myocardial perfusion imaging is assessed, which has a significantly better diagnostic accuracy than electrocardiographic changes alone, with lower false positive and negative rates. Per the 2012 American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines/American College of Physicians/American Association for Thoracic Surgery/Preventative Cardiovascular Nurses Association/Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons (ACCF/AHA/ACP/AATS/PCNA/SCAI/STS) Guidelines for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, "In most studies, stress imaging is estimated to provide a benefit over exercise electrocardiogram (ECG) at a reasonable cost, commensurate with accepted values for cost effectiveness." Use of stress testing in this situation (i.e. ["that is", symptomatic patient at intermediate to high risk for ischemia) is also endorsed by the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association/American Society of Echocardiology/American Society of Nuclear Cardiology/Heart Failure Society of America/Heart Rhythm Society/ Society for Cardiovascular Angiography and Interventions/Society of Cardiovascular Computed Tomography/Society for Cardiovascular Magnetic Resonance/and the Society of Thoracic Surgeons.
(ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS) 2013 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease.