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

Physician 1: The patient is a 54-year-old male who has requested coverage for a coronary magnetic resonance angiography (MRA). The patient has been experiencing chest pain. He underwent a stress echo test during which he exercised for 12.25 minutes. The clinical, EKG, and echo response to exercise were negative for ischemia. The patient had a cardiac calcium scan. There was calcium in the left main coronary artery. The total calcium score placed him in the 37th percentile for age (63% of individuals his age have a higher calcium score). The report stated the patient had a 5 to 10% chance of having significant plaque. Standard coronary angiography (SCA) has been offered to the patient. He has declined because of a shellfish allergy. He has never had IV contrast. Coronary MRA is an emerging technology for evaluating the coronary arteries. It does not use iodine contrast material and is therefore attractive to an individual with contrast allergy. There are not sufficient peer-reviewed reports to confirm coronary MRA is as effective as SCA. It is common practice to perform SCA on allergic individuals with premedication when the clinical indications are sufficient to perform the test. The patient has no objective evidence of significant coronary artery disease. He has not undergone nuclear stress testing as advised by his cardiologist. Coronary MRA is low risk, but has not been sufficiently validated to be beneficial to the patient. Therefore, I have determined that the requested MRA is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 2: The patient is a 54-year-old male with symptoms of exertional chest pain. His cardiac evaluation included a stress test with echo imaging that demonstrated a very high exercise capacity and no evidence of myocardial ischemia or infarction on the electrocardiogram and the echo images. A CT scan of the chest and coronary arteries revealed a mild increase in calcium score and a 5-10 chance of significant plaque in the left main coronary artery. The patient has a history of an anaphylactic reaction to shellfish. The patient and his provider are requesting authorization for magnetic resonance angiography (MRA) of the coronary arteries. The patient does require further testing to rule out significant coronary artery disease. The best medical options currently would be a coronary angiogram or a repeat stress test with myocardial perfusion imaging agents. Although the patient has a history of a severe shellfish allergy, the relationship between shellfish allergy and contrast dye reaction is not definite. In addition, modern cardiac catheterization laboratories utilize noniodinated dye and pretreatment of the patient with steroids, antihistamines and cimetidine will prevent significant dye reactions in almost all patients. MRA of the coronary arteries has not been proven to be as accurate as coronary angiogram or a stress test with myocardial perfusion imaging agents in terms of determining extent of coronary artery disease and prognosis. Based upon the information set forth above, I have determined that the requested MRA is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 3: The patient is a 54-year-old male with atypical, infrequent chest pain (both exertional and nonexertional), no cardiac risk factors, and a negative exercise echo. EBCT shows some calcium, but only the 37th percentile for age predicted values. The patient has requested coverage for magnetic resonance angiography (MRA) as opposed to coronary angiography in light of his contrast dye allergy. The Health Plan has denied the request on the basis MRA is considered experimental. Based on the patients atypical presentation, lack of risk factors, and completely negative stress test, the post-test likelihood of coronary ischemia is very low. EBCT is known to be a nonspecific test (many false positives), which is likely the case here. Overall, it is unlikely the patient has significant coronary stenosis. If his symptoms persist in spite of treatment and the diagnosis remains unclear, then coronary angiography is available to definitively rule out coronary stenosis and can be considered. If coronary angiography is needed, the risk of dye allergy can effectively be overcome by pretreating the patient with steroids and antihistamines. The efficacy of MRA remains unproven and there is no clinical indication for MRA in this setting. Therefore, I have determined that the requested MRA is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.