Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to pre-approve Coronary CT Calcium Scanning. We decided that the Plandoes not have to pre-approve Carotid Duplex Scanning. You asked the Plan to pre-approve Coronary CT Calcium Scanning and Carotid Duplex Scanning. You say that you would like reconsideration as these services are medically necessary.The Plan says that these services are not medically necessary or a covered benefit.We decided that the Planhas to pre-approveCoronary CT Calcium Scanning. The Plan follows Medicare rules. The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Coronary CT Calcium Scanning. Our reviewer says that current ACC guidelines do recommend consideration of coronary CT calcium scoring to determine the absolute need for lipid lowering statin therapy where the risk is not clearly defined or there is concern regarding the need for lifelong medication. Medicare does consider this test covered where there is a clear and needed medically necessary indication.  If the member were to have an elevated calcium score, this would further enhance the evidence and the indication for statin therapy and is therefore medically necessary and meets criteria as it is recommended and also follows the recently published update to AHA/ACC primary prevention guidelines.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Coronary CT Calcium Scanning have been met. Therefore, we decided that the Plan has to pre-approve Coronary CT Calcium Scanning.We also decided that the Plandoes not haveto pre-approve Carotid Duplex Scanning.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Carotid Duplex Scanning. Our physician reviewer found Carotid duplex scanning is apparently being performed to assess carotid intimal medial thickness and not because of symptomatic cerebrovascular type symptoms or evidence of carotid disease on examination. This is not a guideline recommended study for cardiovascular risk assessment at this time. It is not covered by the Medicare criteria in the absence of cerebrovascular symptoms and signs or as a screening test for cardiovascular disease and therefore does not meet criteria.We looked atthis physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Carotid Duplex Scanning have not been met. Therefore, we decided that the Plan does not have to pre-approve Carotid Duplex Scanning.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.