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

Physician 1The patient is a 49-year-old male who has requested authorization for an electron beam computerized tomography (EBCT) heart scan to determine the significance of an indeterminate ECG stress test.The patient has hypertension and a positive family history of premature coronary artery disease (CAD). The submitted records do not address the presence/absence of any other risk factors. On 9/27/02, the patient underwent an EBCT scan. The total calcium score was zero. On 9/23/03, the patient underwent a Bruce Protocol stress test. He exercised 13 minutes (14.8 METs) to 105% of the maximum predicted heart rate for age. No symptoms were reported. A 2mm ST depression was reported as suggestive of myocardial ischemia. The ST depression onset time was not stated. Neither an ECG report nor description of the findings has been submitted. The patients provider has recommended a second EBCT scan to determine whether the stress findings represent the presence of CAD or are a false positive result.ECG stress testing is designed to detect hemodynamically significant CAD. EBCT scans have been shown to yield predictive evidence for the probability of CAD, much in the same way as traditional risk factors for CAD. While a low EBCT calcium score would favor a false positive ECG stress test, it would not exclude the presence of hemodynamically significant CAD. Thus, EBCT scanning would not offer incrementally significant information that is not available in the patients established risk profile of hypertension and family history of premature CAD. Furthermore, on the ECG stress test of 9/27/02, the patient achieved a high level of exercise (14.8 MTS) and did not experience chest pain. These are two negative findings for hemodynamically significant CAD. Hypertension is known to produce false positive stress ECG changes. An EBCT scan was negative two years earlier. It is highly probable the described ECG findings were falsely positive. In an event, EBCT is not likely to be more effective in evaluating the patient for CAD than established testing modalities including stress echocardiography and stress myocardial nuclear perfusion scanning. Based upon the information set forth above, I have determined that the requested EBCT scan 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 2The patient is a 49-year-old male with hypertension, family history of coronary disease, and an abnormal stress ECG. The patient underwent electron beam computerized tomography (EBCT) screening several years ago, which demonstrated no coronary calcium. A request has been made for a repeat EBCT scanning. The Health Plan has denied the request indicating that EBCT is considered experimental.EBCT is not a medically approved or accepted screening or confirmatory test for the diagnosis of coronary artery disease and is not a medically acceptable replacement for other conventional screening tests within the standard of care such as treadmill stress testing. In addition, EBCT is not an accepted substitute for coronary angiography and would not be able to confirm or exclude important coronary obstruction. The use of EBCT in the diagnosis and prognosis of coronary disease currently remains an unproven application of this technology. As such, EBCT scanning is not likely to be more beneficial for the patient than available medically accepted treatment.Based upon the information set forth above, I have determined that the requested EBCT scan 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 3The patient is a 49-year-old male with a history of hypertension and a strong family history of coronary artery disease (CAD). He is taking aspirin and Accupril and had a negative EBCT scan in 2000. On 9/25/03 he underwent a stress test wherein he exercised 13 minutes on a Bruce Protocol without chest pain to RPP 25950. There was 2mm horizontal ST depression reported. The patient now wishes to undergo a repeat EBCT scan. The Health Plan has denied authorization and coverage for the EBCT scan on the basis that it is considered experimental.The patient has risk factors of hypertension and family history of CAD but he is asymptomatic and is able to exercise to a high cardiac workload with appropriate heart rate and blood pressure response. The patients ECG response is suggestive of ischemia.In this case, even if the patients ECG response represents a true finding, the best treatment approach would be aggressive lifestyle modification and risk factor reduction with diet, exercise, treatment of hypertension, treatment of hyperlipidemia, and prophylactic aspirin. This is the same treatment that would be proposed if the ECG response represented a false positive test. EBCT scanning would not result in significant modification to the patients treatment at this time. Follow-up up stress testing to monitor for potential progression is reasonable and in the future may include nuclear imaging as a more accurate test compared to the ECG response to exercise. EBCT scanning has not been demonstrated to provide incremental cardiac risk assessment above that already achieved by a combination of clinical risk indices and stress testing.Based upon the information set forth above, I have determined that the requested EBCT scan 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.