Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve CT scan of the abdomen. We decided that the Plan does not have 
to pre-approve CT scan of the chest.  
 
You asked the Plan to pre-approve CT scan of the abdomen and chest. You say that this is medically necessary. 
The Plan says that there is insufficient clinical information to approve the requested study. 
 
We decided that the Plan has to pre-approve CT scan of the abdomen.  
 
The plan follows Medicare rules. Medicare rules say that CT scans are covered only when they are medically 
necessary.  
 
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 for a CT scan of the abdomen. Our reviewer says that 
the requested CT scan of the abdomen is medically reasonable and necessary. Our physician reviewer found 
that the enrollee has abundant indications for this scan, including persistent abdominal pain, prior history of 
pancreatitis and cholecystectomy as well as ventral hernia repair with mesh.  The possibility of small bowel 
obstruction - at least partial - is a real clinical concern. Ultrasound would not be of use in light of the prior 
pancreatitis and cholecystectomy.  Likewise the evaluation for bowel obstruction would not occur with 
ultrasound. Thus, the requested CT of the abdomen and pelvis is reasonable and should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan of the abdomen have been met. Therefore, we decided that the Plan has 
to pre-approve CT scan of the abdomen.  
 
We also decided that the Plan does not have to pre-approve CT scan of the chest. 
 
The plan follows Medicare rules. Medicare rules say that CT scans are covered only when they are medically 
necessary.  
 
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 for the CT scan of the chest. Our reviewer says that the 
scan of the chest is not medically reasonable or necessary. Our physician reviewer found that the symptoms are 
mainly abdominal in nature. A chest x-ray and bilateral rib series were done 6/25/20 and were negative. Thus, 
the need for CT of the chest has not been established.  It should also be noted that typically the lung bases and 
lower pleural spaces are included on CT of the abdomen and pelvis.  If an abnormality in this area is detected 
on abdominal CT it will be reported and at that time CT of the chest might be indicated. So, at this point CT of 
the chest has not been shown to be medically necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan of the chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve CT scan of the chest. 
 
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.