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

Physician 1: The patient is a 59-year-old male with coronary artery disease established by coronary angiography and treated with angioplasty in June of 2004. He has a recurrence of angina and a stress myocardial perfusion study in November 2005 was positive for ischemia in the anterior lateral left ventricle. The patient has declined coronary angiography. The treating physician has suggested cardiac CT angiography (CTA) as an alternative diagnostic procedure.  The Health Plan has denied the request for CTA on the basis that the diagnostic procedure is experimental/investigational in this clinical context.There is not a scientific consensus that CTA is superior to conventional coronary angiography. As an additional consideration, if angioplasty is required for the treatment of a significant coronary artery stenosis, CTA will not provide an opportunity for intervention.  Therefore, I have determined that the requested diagnostic procedure 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 2: The patient is a 59-year-old male with a known history of coronary artery disease (CAD). He presents with angina and a treadmill cardiolite test that is unequivocal for ischemia. He was appropriately offered cardiac catheterization but refused it. CT angiography (CTA) was then suggested as an alternative. However, the Health Plan considers CTA experimental/investigational for evaluating coronary artery disease and has denied authorization.Contrast-enhanced cardiac CTA involves the use of intravenously administered contrast material to obtain detailed images of the blood vessels of the heart. It is actively being investigated as an alternative to conventional invasive coronary angiography for evaluating coronary artery disease, coronary artery bypass grafts, and coronary artery anomalies. Some small group studies have concluded that CTA is reliable and accurate in a particular class of patients.Despite favorable small studies and emerging clinical applications, CTA has not been accepted as the standard of care over traditional invasive coronary angiography.  There is insufficient evidence that CT angiography is as accurate as conventional coronary angiography for the screening or detection of CAD indications. According to current evidence-based guidelines, conventional invasive coronary angiography is the standard for assessment of coronary arteries.  The most recent American Heart Association (AHA) Scientific Statement continues to recommend the standard workup with stress perfusion studies and conventional angiography, rather than CTA as an intermediate step.  In this particular case, a diagnostic cardiac catheterization and potential revascularization is indeed the next appropriate clinical step. CTA in this setting has little added benefit given the earlier finding of ischemia. If the CTA were to show a high-grade lesion, then diagnostic catheterization would still be indicated. If the CTA showed non-critical disease, the patient might still need medical treatment for angina and require a diagnostic catheterization. In the context of known disease and a previously placed LAD stent, the specificity of the CTA is often lower.  It is important to remember that cardiac catheterization, and not the CTA, is the necessary test prior to revascularization for this patient.  If the patient refuses catheterization and subsequent revascularization, the alternative is medical therapy for ischemia. The findings on CTA would not change this, especially given the unequivocally positive perfusion test.Based upon the information set forth above, I have determined that the requested diagnostic procedure 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: This patient is a 59-year-old male with coronary artery disease (CAD), known stents in the left anterior descending coronary artery, with a complaint of recurrent chest pain. Ischemia in the distribution of the treated artery is documented by stress testing. The patient reports he cannot tolerate any further invasive procedures and is requesting authorization for CT angiography (CTA).  The Health Plan denied the request based upon a determination that the diagnostic procedure is experimental/investigational for the evaluation of the patients CAD.The patient has known coronary disease, recurrent chest pain and significant ischemia in the distribution of the previously treated artery. His symptoms are an ACC/SCAI/AHH Class I indication for coronary angiography with intervention for revascularization as indicated. If the patient refuses invasive therapy as an option for treatment of his coronary disease (percutaneous revascularization or bypass surgery) his only remaining option would be medical therapy.  Such an election would not require additional testing such as CTA, as the results of additional non-invasive studies would not alter the course of his medical management.  Therefore, I have determined that the requested diagnostic procedure 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.