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

Nature of Statutory Criteria/Case Summary: The patient presented for a cardiovascular risk assessment evaluation secondary to a diagnosis of dyslipidemia. The most recent cholesterol level is 209, with low density lipoprotein (LDL) of 114 and high density lipoprotein (HDL) of 78. The patient denied associated symptoms, including decreased activity or exercise tolerance, shortness of breath, swelling, or chest pain. There was no documented history of hypertension or diabetes. The patient was educated and following a low carbohydrate, low fat diet, and exercising five to six times per week. She was referred for advanced lipoprotein testing including lipid particle number and sizing for further risk stratification. The Health Plan has denied the testing at issue as investigational and has determined that this type of blood test is not approvable under the Health Plans criteria because there is no proof or not enough proof that it helps to assess and manage health. The American College of Cardiology (ACC) guidelines do not support use of the advanced lipid testing. Rather, their guidelines recommend the use of standard risk factors and the standard lipid profile to make decisions about lipid management. The guidelines have moved away from specific target values and emphasize use of the pooled risk score analysis for decisions regarding statin therapy. Therefore, the advanced lipoprotein test provided on 11/26/18 was not likely to have been more beneficial for the evaluation of the patients medical condition than any available standard therapy.The patient has a very low 10-year risk of cardiovascular disease (CVD). She has no known CVD and no risk factors other than mildly elevated low density lipoprotein (LDL) cholesterol. The patient's high density lipoprotein (HDL) cholesterol is considered a negative risk CVD factor. There are no current guidelines that would recommend starting lipid-lowering medical therapy in this instance. In light of a low 10-year risk of CVD, continued lifestyle modification, adherence to a recommended diet, and exercise is all that would be currently recommended. As such, the advanced lipoprotein test (CPT code 83704) provided on 11/26/18 was not likely to have been more beneficial for the evaluation of the patients medical condition than any available standard therapy.In this circumstance, the guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Further, there is a paucity of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. As such, the advanced lipoprotein test provided on 11/26/18 was not likely to have been more beneficial for the evaluation of the patients medical condition than any available standard therapy.Final Result: Three out of three reviewers determined that the requested service was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewers are board certified in board certified in internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. The reviewers are experts 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.