Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve CT scan of the abdomen and pelvis. We decided that the Plan does 
not have to pre-approve CT scan of the chest.  
 
You asked the Plan to pre-approve the scans. You say that this is medically necessary. The Plan says that there 
is no documentation of the recommended screenings for increased cancer risks. 
 
We decided that the Plan has to pre-approve CT scan of the abdomen and pelvis.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only 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 CT scan of the abdomen and pelvis. Our reviewer 
says that these scans are medically reasonable and necessary. Our physician reviewer found that Lynch 
syndrome is a very well known predisposing factor to malignancy especially in the colon, ovaries and uterus. 
The enrollee has had uterus and ovaries removed and the CT of 6/10/20 revealed no evidence of metastases. 
There are no published guidelines as to the surveillance of the abdomen and pelvis in patients with Lynch 
syndrome. Thus, CT of the abdomen and pelvis as requested by her oncologist is reasonable based upon the 
oncologist's judgement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan of the abdomen and pelvis have been met. Therefore, we decided that 
the Plan has to pre-approve CT scan of the abdomen and pelvis.  
 
We also decided that the Plan does not have to pre-approve CT scan of the chest. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only 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 a CT scan of the chest. Our reviewer says that the 
scan of the chest is not medically reasonable or necessary. Our physician reviewer found that the 
pulmonologist's note describes a benign appearing 2 mm nodule with calcification in the right lung for which 
surveillance ordinarily would not be required. The pulmonologist then goes on to say that since there was a 
history of breast cancer a follow-up CT of the chest in June, 2021 would be reasonable. Thus, CT of the chest 
is not necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan of the chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve CT scan of the chest. 
 
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.