Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe coronary artery disease, exercise induced hypotension
Treatment: Myocardial perfusion imaging (MPI)
The insurer denied the Myocardial perfusion imaging (MPI).
The determination is overturned.

The patient has a history of multi-vessel coronary artery disease, coronary artery bypass graft surgery and implantation of multiple coronary artery stents subsequently. He was evaluated for episodes of exercise-induced hypotension. An electrocardiogram showed sinus rhythm with an intraventricular conduction delay. An echocardiogram  showed normal left ventricular systolic function and no significant valvular disease. The medical necessity for myocardial perfusion imaging with pharmacologic stress is at issue.

Yes. Based on the documentation provided the proposed service is medically necessary.
This patient has known multi-vessel coronary artery disease and exercise-induced hypotension, which can be a manifestation of myocardial ischemia. Thus, an evaluation for ischemia is warranted. Functional or stress testing to detect inducible ischemia is the most common noninvasive method for diagnosing myocardial ischemia. Options include treadmill testing with electrocardiographic monitoring alone or testing with some form of imaging, such as echocardiography, Single-photon emission computed tomography (SPECT) perfusion imaging or myocardial positron emission tomography (PET) imaging. The diagnostic accuracy of stress testing with imaging is superior to that of exercise stress testing alone. Per the 2012 American College of Cardiology Foundation (ACCF) / American Heart Association (AHA) / American College of Physician's (ACP) / American Association for Thoracic Surgery (AATS) / Preventive Cardiovascular Nurses Association (PCNA) / Society for Cardiovascular Angiography and Interventions (SCAI) /  Society of Thoracic Surgeons (STS) Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, "In most studies, stress imaging is estimated to provide a benefit over exercise electrocardiogram (ECG) at a reasonable cost, commensurate with accepted values for cost effectiveness (i.e., at the threshold for economic efficiency of less than (<) $50,000 per added year of life), a result driven primarily by more frequent angiography and adverse cardiovascular events for those with a negative exercise ECG."  Use of stress testing in this situation (i.e., symptomatic patient at intermediate to high risk for ischemia) is also endorsed by the ACCF/AHA/ American Society of Echocardiography (ASE) / American Society of Nuclear Cardiology (ASNC) / Heart Failure Society of America (HFSA) / Heart Rhythm Society (HRS) / Society for Cardiovascular Angiography and Interventions (SCAI) / Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) /STS 2013 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease and the 2021 AHA/ACC/ASE/ American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain.