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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography of the heart without contrast material with quantitative evaluation of coronary calcium (CPT 75571).Findings:  The physician reviewer found that clinical studies have demonstrated that coronary artery calcium scoring using ultrafast cardiac computed tomography can add predictive value in assessing a patients risk of coronary heart disease. In one study, a score of zero was associated with a coronary heart disease risk of 1-6%, while a coronary artery calcium score over 300 was associated with a risk of 13-26% (Budoff, et al.). However, clinical studies have not shown that coronary artery calcium scoring adds value in the clinical management of asymptomatic patients in whom risk factors are targeted. Mamadu and colleagues examined whether coronary artery calcium scoring in asymptomatic adults might have an effect on behavior modification, risk perception, and medication adherence. The authors noted that while coronary artery calcium screening improved medication adherence, the impact of coronary artery calcium screening on behavioral and lifestyle factors, perception of coronary heart disease risk, and psychosocial effects were not statistically significant compared with baseline. Overall, there is insufficient support in the peer-reviewed literature demonstrating a significant benefit of computed tomography of the heart with quantitative evaluation of coronary calcium in guiding optimal management of this patients hyperlipidemia and obesity in the setting of a strong family history of coronary artery disease. Accordingly, the requested computed tomography of the heart without contrast material with quantitative evaluation of coronary calcium (CPT 75571) 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 of the heart without contrast material with quantitative evaluation of coronary calcium (CPT 75571) 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 requested services are 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 certification in cardiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and clinical cardiac electrophysiology 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.