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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage computed tomography (CT) scan to measure calcium in the coronary arteries. Primary prevention of arteriosclerotic cardiovascular disease requires attention to prevention and management of arteriosclerotic cardiovascular disease risk factors. Elevated serum cholesterol, usually defined by low-density lipoprotein (LDL) cholesterol, is a major arteriosclerotic cardiovascular disease risk factor. A patients 10-year arteriosclerotic cardiovascular disease risk should guide therapeutic considerations in patients ages 40 to 75. The higher the estimated arteriosclerotic cardiovascular disease risk, the more likely the patient will benefit from evidence-based statin treatment. Several risk enhancers are considered when assessing treatment options favoring initiation or intensification of statin therapy. When the risk is uncertain or problematic, coronary calcium score can be aid in assessment. Coronary artery calcium scoring for patients ages 40-75 may be recommended in the setting of a 10-year arteriosclerotic cardiovascular disease risk between 7.5-19.9% for patients not currently on a statin. In this patients clinical situation, there is a lack of history and laboratory data findings provided to support an indication for coronary calcium assessment with CT scanning. The patient has no personal history of coronary artery disease, smoking, diabetes mellitus, or family history of premature coronary artery disease. This patients diagnosis of COVID-19 related complaints of shortness of breath increases his risk and is considered an anginal equivalent, but there are no other enhancing risk factors to support an indication for testing. For these reasons, the requested CT scan to measure calcium in the coronary arteries is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested computed tomography (CT) scan to measure calcium in the coronary arteries is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were 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. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing. Physician reviewer 2 is board certified in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.