Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for a stent and percutaneous transcatheter placement of drug eluting intracoronary stent done. The enrollee initially presented to his physician with complaints of chest pain on exertion. The left sided chest pain has been ongoing for the past days, and he had similar pains in past. The pain radiated to his left scapula and he has had recurrence of several episodes of chest discomfort with exertion. Findings the physician reviewer found that after a one to two min rest after onset of the pain, it resolves. He says that all episodes are under heavy exertion, backpack at high altitudes. He does not have a personal history of heart disease, but his father had coronary artery disease with a cardiac bypass. He had  two routine visits and had no complaint of chest pain.  His cardiologist felt this was suggestive of angina and arranged for stress testing.  A stress test was abnormal, revealing a strongly abnormal stress ECG, anterior ischemia and a suggestion of transient left ventricular dilation.  When he returned to review the stress test results, he reported some chest pain and pressure with exertion.  Cardiac catheterization was scheduled for the next day.  An electrocardiogram (EKG) showed normal sinus rhythm with 1st degree AV block.  The enrollee then underwent left heart catheterization via right radial approach, which showed a proximal left anterior descending lesion of 99% and non-obstructive disease in his other vessels. He underwent stenting of the left anterior descending (LAD) artery.  The procedure was completed without complications and he was instructed to start Effient 10mg daily and aspirin 81mg daily. Review of the record indicates the enrollees only medication prior to coronary angiography was aspirin. No additional medications were discussed or initiated.   According to the medical literature, the effectiveness of coronary revascularization on patients with stable ischemic heart disease must be determined on the basis of additional clinical variables and judgment along with patient preferences. The findings, as reported on the enrollees stress test, are consistent with high risk. For patients with proximal left anterior descending artery disease and intermediate or high risk findings on noninvasive testing, PCI may be appropriate even in the absence of the enrollee being on anti-anginal medications.  In sum, this enrollees history is consistent with ischemia, the stress test was markedly positive and the lesion was proximal and severe. With this combination of findings, selection of PCI as the primary form of management was clinically appropriate. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in internal medicine and cardiovascular disease and is actively practicing. The reviewer is an expert 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 similar medical condition.