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

Physician 1:  The patient is a 57-year-old male with hypertrophic cardiomyopathy and dyslipidemia. He is status post pulmonary vein isolation for atrial fibrillation. He underwent a computed tomography angiography (CTA) in May 2006 to exclude pulmonary vein stenosis. Calcium scoring was also performed to help decide on long-term statin therapy. The Health Plan has denied reimbursement for the CTA on the basis that it is considered investigational.Traditional diagnostic modalities (e.g., CT scanning) are not sufficient to adequately detect pulmonary venous stenosis post ablation. In such cases, CTA is clinically superior and appropriate. Although large, multicenter studies of CTA are still pending, there is adequate evidence of its efficacy to support its use for patients such as this patient. Therefore, I have determined that the diagnostic procedure at issue was 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 2:  The patient is a 57-year-old male who underwent a pulmonary vein isolation (ablation) in July 2005. He has a prior history of hypertrophic cardiomyopathy. A computed tomography angiography (CTA) was requested to exclude pulmonary vein stenosis after ablation. The study revealed an anomalous pulmonary vein, but no evidence of pulmonary vein stenosis. The patient is seeking reimbursement for the CTA, which has been denied by the Health Plan.Although current American College of Cardiology guidelines do not address pulmonary vein stenosis after ablation, many experts feel CTA of the pulmonary veins is the best way to image (especially in the absence of any alternatives). Given the difficulty of detecting and imaging pulmonary vein stenosis, CTA was reasonable in this particular setting and was clinically indicated. It was more appropriate than any other available diagnostic technique. For the reasons set forth above, I have determined that the diagnostic procedure at issue was 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 57-year-old with hypertrophic cardiomyopathy, dyslipidemia, and atrial fibrillation. He is status post a pulmonary vein isolation procedure performed in July 2005. A CT angiography (CTA) was ordered to assess for coronary calcification and to rule out pulmonary vein stenosis status post ablation procedure. At issue is whether the CTA was likely to be more beneficial for evaluation of the patients condition than any other procedure.Conventional CT scanning is generally sufficient to rule out pulmonary vein stenosis status post a pulmonary vein isolation procedure. With respect to diagnosis and treatment of coronary disease, nationally accepted and cardiology association endorsed expert-guidelines have been established and are continually updated. These guidelines do not incorporate the routine use of CTA since the incremental value of CTA, beyond that which can be obtained by risk indices, symptoms and conventional stress testing, is not established. Therefore, 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.