Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to pre-approve the tomographic myocardial perfusion imaging. We decided that the Plan does not have to pre-approve the echocardiogram.
You asked the Plan to pre-approve the echocardiography services and the tomographic myocardial perfusion imaging. You say that the requested tests are medically necessary for treatment of the enrollee's CAD with CABG and for cardiac clearance. You say that the procedures have not been performed and that there has been no recent testing. You say that there are no other records, and that the enrollee was last seen in May of 2019. The Plan says that the records provided did not show that the enrollee has any heart related symptoms. The plan says that the enrollee does not meet the criteria for coverage of the requested services.
We decided that the Plan has to pre-approve the tomographic myocardial perfusion imaging.
The Plan follows Medicare rules. Medicare rules say that nuclear stress testing is covered for risk assessment of re-evaluation of disease in patients who are asymptomatic or have stable symptoms with known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a revascularization procedure within the past two years or greater than two years since the last imaging study. 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 to pre-approve the tomographic myocardial perfusion imaging. Our reviewer says that the criteria for coverage of the tomographic myocardial perfusion imaging have been met. Our physician reviewer found that the enrollee has known coronary disease with CABG more than 5 years ago. Our physician reviewer found that the enrollee has no angina and is now scheduled for noncardiac C-spine surgery. Our physician reviewer found that the enrollee is asymptomatic with known atherosclerotic heart disease and has not had a revascularization procedure within the past two years or greater than two years since the last imaging study.
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 tomographic myocardial perfusion imaging have been met. Therefore, we decided that the Plan has to pre-approve the tomographic myocardial perfusion imaging.
We also decided that the Plan does not have to pre-approve the echocardiogram.
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 to pre-approve the echocardiogram. Our reviewer says that an echocardiogram is not medically reasonable and necessary for the enrollee at this time. Our physician reviewer found there is no known valvular disease, no murmur on physical exam and ventricular function should be adequately assessed on nuclear stress testing. 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 echocardiogram have not been met. Therefore, we decided that the Plan does not have to pre-approve the echocardiogram.