Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Limited systemic sclerosis
Treatment: Chest CT (computed tomography - pictures of the chest)
The insurer denied coverage for Chest CT (computed tomography - pictures of the chest)
The denial is overturned.

This patient was an adult female who was seen for Crest-like syndrome. She had incomplete limited systemic sclerosis with Raynaud's phenomenon, arthralgias, gastroesophageal reflux disease (GERD), dysphagia, and positive centromere antibody. There had been no skin thickening. She had dysphasia and worsening esophageal motility. She had worsening fatigue. She had been treated with Norvasc for Raynaud's. She had hip pain which was shown to be from labral tears and pain in the trochanter. She had injections into the trochanteric bursa. She had COVID-19 (coronavirus disease). She had an infection two months previously and still had dyspnea on exertion and cough.

Physical examination showed the patient to be in no distress. The lungs were clear. There was no joint swelling. The assessment is limited systemic sclerosis, and shortness of breath. She should continue amlodipine and Plaquenil. 

A chest X-ray showed pleural based opacity in the posterior medial right upper lobe that was moderately decreased from prior images. Multiple additional bilateral nodules measuring 6 millimeters (mm) or less were stable and no new opacities have developed. Stable small mediastinal lymph nodes were noted. A computed tomography (CT) scan of the chest showed multiple small and mildly enlarged lymph nodes, with stable configuration with a slightly lobular contour that suggests small underlying lymph nodes.

Previous imaging studies showed abnormalities which were stable. Systemic sclerosis is known to be associated with interstitial lung disease. The demand for pulmonary function tests prior to doing the imaging studies is inappropriate at this time when early detection of interstitial lung disease is crucial to prevent further injury. It is not appropriate that one should wait until pulmonary function abnormalities are demonstrated before instituting therapeutic intervention. Individuals with systemic sclerosis are at risk for developing interstitial lung disease. Early detection is crucial in determining whether more aggressive therapeutic intervention is necessary. The most sensitive diagnostic tool to determine interstitial lung disease is the requested chest CT scan. Given this scenario, the requested CT scan of the chest is appropriate and medically necessary for the purpose of determining whether more aggressive treatment is necessary.

Fischer, A., Patel, N. M., & Volkmann, E. R. (2019), "Systemic sclerosis (SSc) is a progressive and often devastating disease characterized by autoimmune dysfunction, vasculopathy, and fibrosis. Interstitial lung disease (ILD) is identified in the majority of patients with SSc and is the leading cause of SSc-related mortality. Although clinical manifestations and ILD severity vary among patients, lung function typically declines to the greatest extent during the first 3-4 years after disease onset.  Early detection of ILD provides the opportunity for early therapeutic intervention, which could improve patient outcomes. Thoracic high-resolution computed tomography is the most effective method of identifying ILD in patients with SSc; it enables detection of mild lung abnormalities and plays an important role in monitoring disease progression."

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for a chest CT (computed tomography - pictures of the chest) is substantiated.