Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Conn's Syndrome.
Treatment:  Radiology Services (computed tomography angiography).

The health plan denied the request for the radiology services.  The health plan's determination is overturned.

The patient is a male, who presents with Conn's syndrome of hyperaldosteronism without adrenal gland mass/growth identified.  A computed tomography angiography (CTA) (computed tomography angiography as CT venogram [CTV]) is ordered.  This will facilitate the next diagnostic testing ordered, adrenal venous sampling.

The patient has a history of hypertension, hypercholesterolemia, electrolyte imbalance and fatigue, kidney injury, cardiomyopathy, sleep apnea heart catheterization and obesity.  Pertinent past medical records note past surgical history of knee replacements, gastric bypass, cholecystectomy and an appendectomy more recently.  Lab work was reviewed noting an elevated aldosterone, and he also underwent scans not showing adrenal lesion.  Allergies and medications were reviewed.  The current treatment plan is the CTA and CTV followed by adrenal venous sampling procedure to lateralize an adrenal lesion prior to treatment.

What is at issue is the medical necessity of the imaging services required for this patient.

The health plan's determination of medical necessity is overturned, in whole.

Yes, the requested health service/treatment of CTA (computed tomography angiography) (a special kind of picture of the blood vessels in the abdomen, without and with contrast) scan is medically necessary for this patient.

This patient has Conn's syndrome related to hyperaldosteronism and may have an adrenal microadenoma not yet identified.  He may also have bilateral adrenal hyperplasia and would then not have a lateralizing result on the venous sampling procedure.  The venous sampling procedure success would be enhanced with the pre-procedural imaging that is requested.

The patient requires further workup to best treat this, with future potential to remove or ablate the adrenal gland causing this syndrome, once lateralization is found by an adrenal venous sampling being performed.  Therefore, he needs the additional imaging now.  This is not an MRI (magnetic resonance imaging) or specific adrenal imaging to further evaluate for an adrenal microadenoma, nor a PET (positron emission tomography)/CT (computed tomography), but rather CTA to further evaluate the vessel configurations at the adrenal level in order to prepare for and accurately execute the adrenal venous sampling procedure.  This patient needs to have this CTA scan prior to the adrenal venous sampling.

The adrenal venous sampling required will be performed by a skilled practitioner with proper training and credentials.  To be able to access the required veins, especially of the right adrenal gland, a better anatomic localization in advance to aid in this next procedure, is required.  Accurate methods to select patients who have the highest probability of unilateral disease is a key point to the optimal ultimate management of these patients.  In the hypertensive population there is a unique opportunity to cure hypertension in those with primary aldosteronism.  In addition, unilateral adrenal hyperplasia could occur.