Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease

Treatment: Procedure codes 78452 myocardial perfusion imaging (MPI), a special test to check the blood flow to the heart and how well the heart is pumping, and 93306 transthoracic echocardiography (TTE), a special kind of picture of the heart

The insurer denied coverage for procedure codes 78452 and 93306.

The denial is overturned.

This is the case of a woman with a history of ischemic heart disease status post percutaneous cardiac intervention to the first obtuse marginal artery, hypertension, heart failure with preserved ejection fraction, mild mitral regurgitation, diabetes mellitus and hyperlipidemia that presented to the Cardiologist for evaluation. She noted no symptoms of chest pain or dyspnea on exertion. Vital signs were stable (blood pressure [BP] 108/66, pulse 88 beats per minute [bpm]). On physical examination an S4 (most likely pathologic heart sound) extra heart sound and a soft systolic ejection murmur were noted. Twelve lead electrocardiogram (ECG) revealed normal sinus rhythm with "T (interval on ECG) wave abnormality." Low-density lipoprotein (LDL) cholesterol on statin therapy was 90mg/dl [milligrams per deciliter] and HbA1C [Glycated hemoglobin] was 9.9. Perfusion regadenoson with isometric exercise was performed and revealed a preserved left ventricular ejection fraction (LVEF) without ischemia. Echocardiogram revealed a preserved LVEF without significant valvular abnormalities. 

According to the medical records, this patient had no complaints of chest pain or shortness of breath. American Heart Association (AHA)/American College of Cardiology (ACC)/American Society for Echocardiography (ASE) guidelines recommend noninvasive testing for stable ischemic heart disease in patients with prior evidence of cardiac ischemia. (1) 

This patient did not have any cardiac evaluation for more than two years. The risk of death or myocardial infarction can increase after a two year follow up time period and is associated with risk factors such as diabetes mellitus and previous revascularization. (2) Perfusion stress testing after a two-year period of follow up is, at times, an appropriate indication for asymptomatic individuals with a history of coronary artery disease on angiography. (3) ACC/AHA/ASE appropriate use criteria for echocardiography in patients with mild mitral regurgitation recommend surveillance echocardiography every few years. 

The patient had no recent cardiac testing to evaluate for worsening ischemic heart disease, as well as no recent echocardiographic study to assess previously diagnosed mitral regurgitation. Myocardial perfusion testing and echocardiography were medically necessary in this patient with diabetes mellitus and known coronary artery disease requiring revascularization. 

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.  

The insurer's denial of coverage for procedure codes 78452 myocardial perfusion imaging (MPI), a special test to check the blood flow to the heart and how well the heart is pumping, and 93306 transthoracic echocardiography (TTE), a special kind of picture of the heart, is overturned. Medical necessity is substantiated.