Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Systemic Sclerosis

Treatment: Transthoracic echocardiogram

The insurer denied coverage for transthoracic echocardiogram

The denial is overturned

This case involves a patient diagnosed with systemic sclerosis who was recommended for a transthoracic echocardiogram.  The pulmonary function test included an echocardiogram 2D complete.  The conclusion noted that the left ventricle was normal, ejection fraction was 67% (percent) with normal right ventricular systolic function and trivial mitral regurgitation.  The patient had normal pulmonary artery pressure with no other significant abnormalities noted.  The office visit noted the patient was being seen for management of scleroderma.  The patient was compliant with Plaquenil 200 mg (milligram) daily and denied heartburn, palpitations, or difficulty swallowing.  The patient reported color changes of the hands and feet but was good about cold precautions.  Laboratory testing showed a low white blood cell (WBC) count of 3.3.  The patient had a noted history of leukopenia but denied frequent infections.  The treating physician submitted a radiology requisition form for the patient to undergo transthoracic echocardiogram due to a history of nonrheumatic tricuspid valve insufficiency.  At the time of the visit, the patient had no evidence of significant gastrointestinal, cardiac, or pulmonary issues.  The patient had noted Raynaud's with currently mild fluctuating symptoms.  The patient had a history of echocardiogram showing normal pulmonary artery pressure and no significant valvular disease.  Pulmonary function testing showed mildly reduced oxygen diffusion not corrected for hemoglobin.  The patient was a non-smoker and vital signs were stable.  A letter stated that patients with systemic sclerosis are at higher risk of developing pulmonary hypertension, which is a major contributor to mortality in these patients.  This can affect up to 10% of individuals with a diagnosis of systemic sclerosis and best practice recommendations are for asymptomatic patients with systemic sclerosis to be screened annually for early detection of systemic sclerosis associated pulmonary hypertension.  Thus, the recommendation was for the patient to undergo transthoracic echocardiogram for yearly evaluation.  The patient received a notice of adverse determination stating that the transthoracic echocardiogram was denied and not considered medically necessary.  The indication was that the patient had no chest pain, breathing problems, or heart beath problems.  Recommendation was given for office visit notes less than 6 months old.  This review pertains to the denial of coverage for transthoracic echocardiogram.

Literature notes that systemic sclerosis (SSc) is a complex connective tissue disease with multiple clinical and subclinical cardiac manifestations.  SSc can affect most structural components of the heart, including the pericardium, myocardium, valves, and conduction system through a damaging cycle of inflammation, ischemia, and fibrosis.  Given the high prevalence of right ventricular (RV) dysfunction and pulmonary hypertension (PH) in patients with SSc, current guidelines recommend echocardiographic screening of all SSc patients in order to detect and implement PH therapy as early as possible.  The patient was scheduled to undergo a yearly transthoracic echocardiogram for monitoring and evaluation of their systemic sclerosis.  While the patient was not symptomatic at the time of the most recent office visit, ongoing yearly monitoring of the patient's condition is essential to maintain pulmonary and heart health (1).  As such, the request for transthoracic echocardiogram is medically necessary.  The prior determination is overturned.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for transthoracic echocardiogram is substantiated.