Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  99% thrombotic occlusion of the left circumflex

Treatment:  Extracranial bilateral study

The insurer denied coverage for extracranial bilateral study.  The denial was reversed.

This patient is a male with a past medical history of hypertension, hyperlipidemia and coronary artery disease.  He is status post Non-ST Elevation Myocardial Infarction (NSTEMI) in mid- 2012 and had a coronary angiogram at that time, which showed a 99% thrombotic occlusion of the left circumflex.  This was successfully stented with drug-eluting stents.  There was a residual 30-40% stenosis in all three major vessels.   An echocardiogram done in late-2014 showed a left ventricular ejection fraction (LVEF) of 55%, grade 2 diastolic dysfunction, and mitral annular calcification.  He presented for a routine visit in mid-2019.  His review of systems noted left shoulder pain, and no other symptoms were described.  His vital signs revealed a blood pressure of 144/70, a pulse of 70, and a body mass index (BMI) of 31.  On physical exam, he was in no acute distress, and no abnormalities were described.  A letter was submitted by the patient's Cardiologist to appeal the insurance company's decision concerning assessment for carotid stenosis.

Carotid Duplex Ultrasonography (CDUS) is one of the non-invasive imaging modalities used to evaluate for carotid artery stenosis.  However, it is often used in patients with coronary artery disease (CAD), peripheral artery disease (PAD), before heart surgery, syncope and non-specific neurological symptoms, although its value is unclear.  

Most professional societies have moved away, or are moving away, from recommending screening for carotid artery stenosis.  In 2011, The American Heart Association (AHA) and the American Stroke Association (ASA) issued extensive guidelines for the primary prevention of stroke.  They note that medical therapy has significantly changed since the clinical trials that showed a benefit to surgical intervention, and that there is now uncertainty whether to recommend surgery in asymptomatic patients.  In those guidelines, they do not recommend screening in the general population for asymptomatic carotid stenosis.  In that same year (2011), the American Heart Association [AHA], American Stroke Association [ASA], and 12 other groups issued a joint statement of guidelines that stated that carotid duplex screening is not recommended for routine screening in asymptomatic patients who have no clinical manifestations of or risk factors for atherosclerosis.  They do state that it is reasonable to screen those with symptomatic CAD or peripheral vascular disease, but it is unclear if a positive screen would change those patients' management.  As of July 2014, the US Preventative Services Rask Force [USPSTF] gives screening for asymptomatic carotid stenosis a "D" recommendation, meaning that there is a "moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits." (2)

The patient had a past medical history that included hypertension, hyperlipidemia and CAD, with a history of NSTEMI and coronary stenting.  The report indicated that following the procedure, all three major vessels had a 30-40% stenosis.  The literature cited makes it clear that carotid duplex ultrasonography (CDUS) has questionable indications in asymptomatic patients.  However, although the risk/benefit ratio may have changed, the guidelines leave some room to perform the study in those with increased atherosclerotic risk.  This patient has some increase in risk based on his age, his history of hypertension, hyperlipidemia, persistent disease in all three of his major coronary arteries and his increased body mass index (BMI) of 31.

For these reasons, the healthcare plan did not act reasonably, or with sound medical judgment, or in the patient's best interest.  The denial of coverage for the extracranial bilateral study should be reversed.

The carrier's denial of coverage for CPT 93880 - extracranial bilateral study is reversed.  The medical necessity is substantiated.