Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Computerized tomography angiogram (CTA) of the abdomen and pelvis

The insurer denied coverage for computerized tomography angiogram (CTA) of the abdomen and pelvis

The denial is upheld 

This case involves a patient with a subject for review for the denial of coverage for computerized tomography angiogram (CTA) of the abdomen and pelvis.

A computed tomography (CT) abdomen/pelvis was done to assess for biliary pathology versus diverticulitis versus colitis. The imaging revealed mild bowel wall thickening in the jejunum, nonspecific, however possibly representing enteritis. A small hiatal hernia was also seen, as well as multiple bilateral ovarian cysts were also seen that may represent polycystic ovarian syndrome and mild splenomegaly.  

Another CT abdomen/pelvis done for abdominal/flank pain, stone suspected, right flank and inguinal pain. Imaging showed no obstructing urinary tract calculus or hydronephrosis, punctate non-obstructing renal calculi bilaterally, normal appendix, and mild splenomegaly which was decreased form the prior exam. 

The patient presented for their annual obstetrics and gynecology (OBGYN) exam. The patient reported that they are sexually active and denied pain or bleeding with intercourse. The patient reported menses have been very infrequent, 2-3 each year, no breast concerns reported, and the patient requested to see a polycystic ovarian (PCO) specialist.

The Cervical Pap Smear done was negative for intraepithelial lesion or malignancy. 

In this case, the patient is gravida (G) 5 para (P) 5 with a significant past medical history of polycystic ovarian disease. The patient stated that they had significant pain and cramping when symptoms started with their second pregnancy 11 years ago. It was significantly exacerbated during the pregnancies with their fourth and fifth children, and over the last few years, the patient has had worsening pelvic symptoms. Upon review of systems, the patient was noted to have pelvic discomfort, heaviness and/or "dragging" feeling, sharp pelvic pain in the groin/inguinal region, severe bloating and/or gassiness, hemorrhoids, and refractory diarrhea. 

Previous CT's of the abdomen/pelvis were done.  During a recent visit, a CTA was ordered.

The request was previously denied as not medically necessary. The healthcare provider stated that there is a concern for a problem (condition) that causes chronic pelvic pain. Per the insurer, the request cannot be approved because the results of a prior ultrasound (picture study using sound waves) must have failed to find the source of your problem. A study similar to the one requested has recently been performed. The results of that study showed the doctor what they needed to see in order to treat the condition. No additional imaging was necessary at that time. 

Based on the review of medical records received, the patient has not had a prior ultrasound that may be inconclusive and may require additional diagnostic imaging. Per the referenced literature, ultrasound is, in most cases, the first imaging technique used in abdominal pathology and can be sometimes sufficient for a complete diagnosis. As such the denial of coverage for computerized tomography angiogram (CTA) of the abdomen and pelvis is upheld and is considered not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for computerized tomography angiogram (CTA) of the abdomen and pelvis services is not substantiated.