Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Occlusion in the LAD 

Treatment: Current Procedural Terminology (CPT) 92978 and 93458- Intravascular Optical Coherence Tomography (OCT)

The insurer denied coverage for Current Procedural Terminology (CPT) 92978 and 93458- Intravascular Optical Coherence Tomography (OCT).

The denial is overturned.

The patient is a male who presented to another hospital with a complaint of chest pain and then was transferred to a regional medical center to be evaluated by cardiology. The patient claimed that his chest pain worsened with minimal exertion such as walking to the bathroom. The patient described the pain as being present in the chest with radiation to the left arm. The patient denied any abdominal pain and he complained of some nausea, but denied any vomiting. The patient denied shortness of breath or cough. The patient stated that the pain was 6/10 in intensity, more or less continuously present and worsened with ambulation. The patient stated that he had chest pain about several months prior and he had a negative stress test. The patient had a past medical history significant for hypertension, hyperlipidemia, family history of coronary artery disease (CAD) and had presented to the hospital for evaluation of chest pain. The final arteriogram revealed no stenosis of the LAD. The first diagonal, which is a moderately to severely tortuous vessel had an 80-90% occlusion. Based on the tortuous of the vessel it was decided to treat the lesion medically. It was recommended that the patient take dual antiplatelet therapy for at least one year and cardiac rehab was recommended. The patient's medication list at the time of discharge included amlodipine, aspirin, atorvastatin, carvedilol, ticagrelor, and valsartan- HCTZ.

ILUMIEN I is the largest prospective, non-randomized, observational study of percutaneous coronary intervention (PCI) procedural practice in patients undergoing intra-procedural pre- and post-PCI fractional flow reserve (FFR) and optical coherence tomography (OCT). These investigators report on the impact of OCT on physician decision-making and the association with post-PCI FFR values and early clinical events. Optical coherence tomography and documentary FFR were performed pre- and post-PCI in 418 patients (with 467 stenoses) with stable or unstable angina or NSTEMI. Based on pre-PCI OCT, the procedure was altered in 55% of patients (57% of all stenoses) by selecting different stent lengths (shorter in 25%, longer in 43%). They concluded that physician decision-making was affected by OCT imaging prior to PCI in 57% and post-PCI in 27% of all cases. (1)

This patient presented to the hospital with unstable angina with T-wave changes on his EKG. A coronary angiogram showed a 90% occlusion in a large LAD. This patient required percutaneous intervention (PCI) which was done with excellent results. The question that is raised is the use of intravascular optical coherence tomography (OCT), which is an imaging procedure which is commonly done in up-to-date angiographic laboratories, with the lesions such as this. There is extensive literature concerning this technique. There is literature comparing OCT with IVUS (another imaging technique) as well as with standard angiographic guided PCI. The literature shows that the OCT group had the lowest in-hospital event rate. There was a significant difference in mortality between patients who had OCT guided PCI compared with patients who underwent either IVUS guided PCI or angiographic guided PCI. Thus, it is considered that this requested service was likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for Current Procedural Terminology (CPT) 92978 and 93458- Intravascular Optical Coherence Tomography (OCT) should be overturned.