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

Physician 1:  The patient is a 63-year-old male with a history of coronary artery quadruple bypass surgery.  The patients provider states a myocardial perfusion imaging performed in May 2006 revealed a moderate degree of reversible ischemia in the basal to mid inferior and basal to mid inferolateral segments. The patient had a normal treadmill test. The patients provider has recommended a CT angiogram, which has been denied by the Health Plan on the basis that it is considered investigational.CT angiography (CTA) is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease, and is not a medically accepted replacement for other conventional screening tests within the standard of care such as treadmill stress testing. CTA is also not a medically accepted substitute for coronary angiography, as CTA would not be able to accurately confirm or exclude important coronary obstruction. The use of CTA in the diagnosis and prognosis of coronary artery disease currently remains an unproven application of this technology. Therefore, I have determined that the requested diagnostic procedure is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2:  The patient is a 63-year-old male who had a CABG in 1992. He reports he has undergone annual thallium and echo evaluation. There is no documentation of a symptom change. He underwent a treadmill thallium that showed a new moderate degree of reversible ischemia in the inferior lateral distribution. Otherwise, the patient is able to achieve 13 minutes on a treadmill without chest pain and his EF is 60%. His cardiologist has requested a CT angiography (CTA) prior to deciding on traditional angiography towards possible coronary revascularization. The Health Plan has denied coverage for the CTA citing a lack of proven efficacy.CTA is not currently recommended as standard procedure in the workup for coronary artery disease or treatment of stable angina. While new ACC guidelines regarding CTA are anticipated soon, they have not as yet been published. Many have urged caution prior to widespread use of CTA until its role has been studied and consensus achieved on when to use it appropriately. CTA is especially problematic in patients with a high degree of coronary calcification (patients with extensive CAD) as its specificity decreases.However, in the case of this patient he has 14-year-old coronary artery grafts. Grafts greater than five years and especially saphenous grafts greater than ten years are at high risk for stenosis or closure. A change in the perfusion study with increased ischemia may indeed merit further study. CTA has not been well studied in this role but is indeed increasingly used especially with old post CABG patients. One study does demonstrate its ability to determine if the grafts are open or patent while not addressing management issues. In this case, CTA will help determine if the grafts are open and where the grafts are. Knowing the location of the grafts by CTA, and which are occluded and do not need to be found will save the patient contrast and fluoro and catheter manipulation risk. In a CABG of 14 years with unclear grafts location, these issues are important and offer an advantage in the subsequent traditional angiography. Given this, I have determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3:  The patient is a 63-year-old male with an established history of coronary artery disease (prior CABG). A myocardial perfusion study demonstrated moderate degree of reversible ischemia. He has an ACC/AHA 11a indication for coronary angiography. His treating physician has recommended a CT angiogram. The Health Plan has denied coverage for the procedure on the basis that it is considered experimental/investigational.CT angiography is an investigational test that has not been proven to be more beneficial than conventional coronary angiography. Its principal advantage is that the procedure is non-invasive. The use of CT angiography in the diagnosis and prognosis of coronary disease currently remains an experimental/investigational application of this technology. As such, the use of CT angiography in this case is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.