Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve the stress echocardiogram. We decided that the Plan does not have to pre-approve the transesophageal echocardiogram.
You asked the Plan to pre-approve the stress echocardiogram. You say that this is medically necessary. The Plan says that the records do not show a standard stress test.
We decided that the Plan has to pre-approve the stress echocardiogram.
The Plan follows Medicare rules. Medicare rules say that services are covered 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 stress echocardiogram. Our reviewer says that this requested test is medically reasonable and necessary. Our physician reviewer found that based on the records provided the patient has no documented cardiac symptoms, a systolic murmur on physical exam and findings of left ventricular hypertrophy with mild strain pattern on electrocardiography. In this circumstance a transthoracic echocardiogram to assess left ventricular hypertrophy and the cause of the murmur is reasonable, appropriate and considered standard accepted practice in the medical community. Coverage criteria for transthoracic echocardiography are met since hypertensive and valvular heart disease are both covered indications for the procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the stress echocardiogram have been met. Therefore, we decided that the Plan has to pre-approve the stress echocardiogram.
We also decided that the Plan does not have to pre-approve the transesophageal echocardiogram.
The Plan follows Medicare rules. Medicare rules say that services are covered 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 transesophageal echocardiogram. Our reviewer says that this requested test is medically reasonable and necessary. Our physician reviewer found that there is no covered indication for a transesophageal echocardiogram, in my opinion. Also, since there are no documented symptoms or electrocardiography findings concerning for coronary ischemia, the records do not support the medical necessity for stress testing of any kind. Screening stress testing, even in patients with increased coronary risk, has not been shown to improve cardiac outcome. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transesophageal echocardiogram have not been met. Therefore, we decided that the Plan does not have to pre-approve the transesophageal echocardiogram.
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.