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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intravascular optical coherence tomography for evaluation of the enrollee who presented with chest tightness. Findings:  2/3 of the physician reviewers found that while the research in intravascular optical coherence tomography (OCT) for assessing coronary artery disease has advanced over last several years, it has not been proven with any long term study or trial that it is better than other standard available options. OCT is a high resolution catheter based imaging modality that helps visualization of coronary artery disease. It has potential applications including coronary artery lesion assessment, as an adjunct to percutaneous coronary intervention (PCI) in treatment of these lesions and follow up evaluation after coronary stent placement. There are several studies published since 2002 comparing intravascular OCT with intravascular ultrasound (IVUS) in the coronary artery lesion assessment. Both these techniques rely on high resolution images of the coronary artery plaque for accurate assessment which would help in planning treatment and follow-up. While there are advantages and disadvantages involving both these techniques, the published literature do not support the superiority of intravascular OCT over IVUS in lesion characterization. Moreover, most of these studies are limited due to small size and lack of randomization.  OCT may have some value in clinical research but its role in assisting clinicians with treatment decisions has yet to be established. Accordingly, the appropriate role for OCT in routine clinical decision making has not been clearly defined. For these reasons, intravascular OCT was not likely to have been of greater benefit than the available standard options for the evaluation of this patients medical condition. Final Result: 2/3 of the reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.