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

Physician 1:  The patient is a 56-year-old woman who has a history of hyperlipidemia and smoking. She has been diagnosed with chest pain syndrome, she has intermittent VEA (ventricular ectopic activity) and she is treated with flecainide for variable palpitations. The specific arrhythmia that is being treated with flecainide was not described nor is the precise diagnosis associated with the palpitations. A stress test or perfusion study is not included in the documentation. The September 2006 providers note indicated the EKG was NSR, NL or normal. The provider also noted the patient did not have recurrent chest pain, but had intermittent VEA and chest pain with VEA. The provider indicated that CAD should be ruled out and referred the patient for CT angiography (CTA). CTA was performed in September 2006 and was reported as normal. The patients request for reimbursement was denied by the Health Plan citing the experimental/investigational nature of the diagnostic procedure.The 2006 appropriateness criteria do not as yet incorporate the routine use of CTA, as the incremental value of the technology has not been established. The current criteria for the use CTA in the detection of coronary artery disease (CAD) indicates it is not appropriate in the symptomatic patient with an intermediate pre-test probability of CAD, an interpretable EKG and the ability to exercise. While the guidelines indicate CTA is appropriate for a symptomatic patient when there is an uninterpretable EKG or an inability to exercise, that is not the case in this instance. Flecainide therapy is not included as an appropriate indication in the CTA guidelines nor do the records include any other factors that would establish a basis for the application of CTA. The guidelines indicate SPECT perfusion imaging is appropriate in the work up of chest pain syndromes in patients with an intermediate or high probability of CAD. Given the documentation provided and the current guidelines, I have determined that the diagnostic procedure at issue was 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 56-year-old female with exertional chest pain and hyperlipidemia. Her provider also noted palpitations and ventricular ectopy. The record indicates that a previous nuclear stress test was reported as normal. CT angiography was preformed in September 2006 on the recommendation of the patients provider and a request for reimbursement is pending. The Health Plan considers this an investigational procedure and has denied reimbursement.CT angiography is not thus far, a generally accepted screening or confirmatory test for the diagnosis of coronary artery disease. It is not a medically accepted replacement for conventional screening tests such as treadmill stress testing or an appropriate substitute for coronary angiography. CT angiography 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 remains an experimental/investigational application of this technology. Consequently, I have determined that the diagnostic procedure at issue was 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 3:  The patient is a 56-year-old female described as having palpitations, chest pain syndrome, hyperlipidemia and PVCS. She is currently treated with flecainide. CT angiography was recommended by her cardiologist to rule out coronary artery disease (CAD) and was performed in September 2006. The patients request for reimbursement was denied by the Health Plan on the basis that CT angiography is considered experimental/investigational in this clinical context.CT coronary angiography is a rapidly developing technology for visualization of coronary arteries and coronary artery bypass grafts. It has variable sensitivity from 85% to 100% and specificity from 85% to 97%. It is not recommended as an alternative to invasive coronary angiography at the present time and it is not recommended for screening asymptomatic patients including those at high risk. A recently released consensus document concluded that CT angiography may be appropriate in some circumstances. Specifically, (1) in the evaluation of chest pain in patients with an intermediate pre-test probability of CAD who had an uninterpretable EKG or who were unable to exercise; (2) the evaluation of suspected coronary anomalies; and (3) the evaluation of acute chest pain with an intermediate pre-test probability of CAD and no EKG or enzyme evidence of acute infarction. In this case the patient is symptomatic; however there is no reference to an uninterruptible EKG or an inability to exercise. CT angiography is still considered investigational for patients such as this one.Based upon the information set forth above, I have determined that the diagnostic procedure at issue was 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.