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

Physician 1: The patient is a 50-year-old man who has cardiomyopathy (type unspecified). In addition, he has risk factors for coronary artery disease. The patient has a history of previous discordance between stress nuclear scanning and conventional coronary angiography. The patients provider has recommended an electron beam angiogram for further evaluation of the patients condition. The Health Plan denied the request on the basis that electron beam angiography is considered experimental. The Health Plans denial should be upheld. While electron beam angiography is a promising, non-invasive test for evaluating coronary anatomy, technical limitations make this test less sensitive than coronary angiography. Coronary angiography is the gold standard for detecting luminal narrowing. To date, a sufficient number of peer-reviewed studies have not been performed to establish the efficacy of electron beam angiography. Therefore, I have determined that the requested electron beam angiogram 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 2: The patient is a 50-year-old male with a history of left bundle branch block, chronic chest pain, abnormal nuclear stress tests, reduced EF, and normal coronary angiography after an abnormal nuclear exam. His only documented cardiac risk factor is a family history of coronary disease. As the patient has continued to have chest discomfort without change in ECG, a repeat nuclear stress test was performed in September 2004. The test showed no change in a mild ischemic pattern of the anterior septum and anterior wall compared to the scan in 2002 (prior to angiography), presumably a false positive finding. The scan also showed a new mild inferoseptal defect that is said to improve on stress images; this does not appear to be a pattern of ischemia as the conclusion states. A request has been made for an electron beam angiogram to further evaluate the patients condition. The Health Plan has denied this request on the basis that electron beam angiography is considered experimental. Review of the submitted clinical evidence indicates the patient has chronic symptoms with known angiographically normal coronary arteries, and falsely positive nuclear scans with no new ischemic territories. As such, further evaluation for coronary disease with electron beam angiography is not medically necessary. Furthermore, even if additional evaluation for coronary stenosis was necessary, electron beam angiography has not been shown to be as sensitive as standard angiography in detecting coronary stenosis, particularly for distal lesions. Therefore, I have determined that the requested electron beam angiogram 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 50-year-old male with a history of cardiomyopathy, left bundle branch block, and chest pain. He underwent a previous nuclear stress test, which was abnormal, and cardiac catheterization at that time did not show coronary artery disease. The patient had a repeat nuclear stress test for chest pain, which remained abnormal. The patients provider recommended an electron beam angiogram for the diagnosis or exclusion of important coronary artery obstruction. The Health Plan has denied authorization for the requested electron beam angiogram on the basis it is considered experimental. Electron beam angiography is not a medically approved or accepted screening or confirmatory test for the diagnosis of coronary artery disease. Furthermore, electron beam angiography is not a medically acceptable substitute for coronary angiography, as the former would not be able to accurately confirm or exclude important coronary obstruction. The use of electron beam angiography in the diagnosis and prognosis of coronary disease remains an unproven application of the technology. Therefore, I have determined that the requested electron beam angiogram 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.