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

Physician 1: The enrollee is a 60-year-old woman who may have chest pain syndrome. Her cholesterol is elevated to 221, but with a favorable ratio of HDL to LDL (HDL= 83, LDL= 110). The patients only reported risk factors are that is 60-year-old and apparently has family history of coronary artery disease. Documentation of other risk factors (smoking, diabetes and hypertension) are not provided.EBCT is not recommended as a general population screening test for coronary artery disease by the ACC or by the USPSTF guidelines. The standard of care would be to work up her chest pain with a stress test (treadmill) or a perfusion stress test (if EKG is abnormal). In symptomatic women with an intermediate likelihood of coronary artery disease, either an exercise treadmill test or an exercise echocardiogram is appropriate for initial screening. A patient who is symptomatic or deemed high risk would be best served with standard testing. If not symptomatic, screening for coronary artery disease is not recommended by USPSTF - unless a patient is considered high risk and has adult onset diabetes mellitus. Based upon the information set forth above, I have determined that the requested EBCT is 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.Physician 2: The patient is a 60-year-old asymptomatic female who has requested an electron beam computed tomography (EBCT) to screen for coronary artery disease. The patient indicates she has a high cholesterol, positive CRP and family history of premature coronary artery disease. The records indicate the total cholesterol is 212, LDL 110 and HDL 83. This is a low risk cholesterol profile.EBCT is an experimental procedure for the detection of coronary calcium deposits. The presence of coronary calcium has been correlated with the risk of future coronary events. The test is not capable of detecting physiologic significant coronary obstruction. Determining whether a patient has conventional risk factors remains superior to EBCT for determining risk for future coronary events. Therefore, I have determined that the requested EBCT is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 60-year-old woman with cardiac risk factors of a positive family history for coronary artery disease and mild hyperlipidemia. She also has an elevated CRP. There is reference to infrequent chest pain per patients report, but there is no documentation of this in the medical records provided for review. The patient wishes to have an EBCT scan to further evaluate for coronary artery disease.The current guidelines established by panels of experts in the field and updated on a regular basis detail recommendations for coronary risk factor reduction (diet, exercise, cholesterol management, smoking cessation) and treatment of coronary artery disease. These guidelines presently do not incorporate the use of EBCT. Moreover, there is no data to support that EBCT has incremental benefit over a combination of risk factor modification and conventional stress testing, when indicated. Therefore, I have determined that the requested EBCT is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.