Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ventricular tachycardia
Treatment is for a cardiac MRI
The insurer denied coverage for a cardiac MRI (magnetic resonance imaging) 
The denial is upheld

This case involves a patient diagnosed with non-sustained ventricular tachycardia, paroxysmal ventricular tachycardia, sick sinus syndrome, dual-chamber pacemaker, and hyperlipidemia who underwent a cardiac MRI with and without intravenous contrast with reports that he was undergoing evaluation for myocardial characterization. The impression was of a normal size left ventricle with normal systolic function of 60%. He had a small amount of nonspecific bandlike mid wall late gadolinium enhancement of the basal interventricular septum, qualitatively similar to a prior examination. The visit note stated the patient was seen for follow-up denying angina, chronic heart failure, palpitations, or syncope. He was compliant with medications with no side effects, was exercising regularly, felt well overall, with his examination findings showing stable vital signs and no cardiovascular abnormalities on assessment. The report referenced to an undated EKG (electrocardiogram) with normal findings. The report provided no further information pertaining to the recommendation for an MRI.  

The healthcare plan acted reasonably and with some medical judgment and in the best interest of the patient.

The cardiac imaging guidelines state that indications for a cardiac MRI include a need to assess myocardial viability (to differentiate hibernating myocardium from scar) when necessary to determine if revascularization should be performed. An MRI may also be indicated for assessment of global ventricular function, myocardial composition, and mass if a specific clinical question is left unanswered by a recent echocardiogram and the results will affect patient management. An MRI may be indicated for pre and postoperative congenital heart disease assessment, for coarctation of the aorta, for arrhythmogenic right ventricular dysplasia or arrhythmogenic right ventricular cardiomyopathy suspicion when the patient has specific abnormalities. An MRI may be indicated for differentiating constrictive pericarditis from restrictive cardiomyopathy, for evaluating a cardiac tumor or mass when an echocardiogram is inconclusive, and in order to evaluate valvular heart disease with an echocardiogram as a conclusive. An MRI may be indicated for pulmonary vein anatomy for planned ablation procedures in patients with atrial fibrillation, a patient suspected of having a cardiac thrombus when a echocardiogram is inconclusive, for patients needing right ventricular function evaluation, if a recent echo (echocardiogram) has been done and there is documented need for performing a cardiac MRI in order to resolve an unanswered question. An MRI may be recommended for shunting through a VSD (ventricular septal defect), if a recent echo has been done, including a bubble study, and there is documented need to perform a cardiac MRI in order to resolve an unanswered question, and for conditions that would not require an echo prior to an MRI such as anomalous coronary arteries, assessing coronary arteries and Kawasaki's disease, family disease, and for an initial evaluation for cardiac sarcoidosis. Literature notes that magnetic resonance imaging (MRI) has become a commonly used non-ionizing radiation dependent imaging modality which has an excellent spatial resolution with the capability to provide physiological information. 

The insurer's denial of coverage for a cardiac MRI is upheld. Medical Necessity is not substantiated.