Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1:  The patient is a 57-year-old woman with hyperlipidemia and complaints of chest pain and shortness of breath. In November of 2000 she underwent a cardiac catheterization, which showed Normal left ventrical function. No angiographic evidence for significant epicardial coronary artery disease. Small distal left anterior descending either normal variant and a small eddy, although cannot rule out diffuse concentric distal left anterior descending disease to account for the patients apical ischemia and atypical chest discomfort. An adverse reaction to the catheter/anesthesia is not found in the dictated report.In March 2005 she underwent a stress myoview SPECT scan. She had no ischemia. The patient is unable to tolerate statins for hyperlipidemia. Per the submitted records, she is not on cardiac medications such as beta-blocker or nitrate. A CT angiography has been recommended.At issue is whether a CT angiography is likely to be more beneficial for evaluation of the patients medical condition than any available standard diagnostic procedure.The American College of Cardiology (ACC) has published guidelines regarding the   appropriateness of CT angiography. Based on the patients last cardiac catheterization, it is unclear if she has existing coronary disease (diffuse distal LAD disease) or a small distal LAD which is possibly a normal variant. She had a normal perfusion study at 9 minutes in March 2005. This clinical description of evaluation of chest pain places her in the Detection of LAD: Symptomatic Table I Indication of the guidelines. Both Indication 1 (Intermediate pre-test probability) and Indication 3 (High-pre test probability of CA) are not as yet clearly appropriate indications for CT angiography. (They are referred to as uncertain and inappropriate respectively.) Furthermore, the documentation provided does not support Indication 2 (ECG uninterpretable or unable to exercise), which is an appropriate indication.Thus, given the documentation provided and the current ACC guidelines, there is insufficient evidence that CT angiography is clinically indicated or appropriate in this case. Alternatives include empiric treatment of coronary artery disease, treatment as syndrome X (microvascular angina), work-up of other causes of chest pain/dyspnea, traditional perfusion stress testing and continued treatment of cardiovascular risk factors. Traditional angiography could be considered if further studies or symptoms become high risk.Based upon the information set forth above, I have determined that the requested diagnostic procedure is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 2:  The patient is a 57-year-old woman with a long history of chest discomfort in the setting of cardiac risk factors of smoking and hyperlipidemia. Initial nuclear stress test of September 2000 revealed an apical defect prompting coronary angiography to be performed. No focal epicardial stenosis was identified on angiography (small distal LAD-either normal variant or diffuse concentric disease). A follow-up stress test in March 2005 was completely normal and now the patient presents with recurrent chest discomfort. She is on aspirin and is intolerant to statins. Her provider has proposed a CT angiography, for which the Health Plan has denied coverage.In this case, the patients chest discomfort is not clearly linked to coronary ischemia since coronary angiography showed no focal stenosis, the small distal LAD identified may be a normal variant, and follow-up stress testing failed to reveal any provable ischemia. The patients current symptoms are described as the same, so the development of a progressive coronary process is less likely. It would be most appropriate to repeat stress testing as a first step if evaluation of recurrent chest discomfort is thought to be necessary. CT angiography to assess for stenosis and to evaluate the distal LAD would only provide anatomic information and would do nothing to assess the functional significance of any abnormalities identified. There is no evidence that CT angiography would yield incremental value over stress testing in this case.Based upon the information set forth above, I have determined that the requested diagnostic procedure is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 3:  The patient is a 57-year-old female with a history of chest pain and possible coronary disease based on her previous work-up. She is seeking authorization and coverage for a CT angiography. The Health Plan has denied this request citing a lack of proven efficacy of CT angiography in this clinical scenario.CT angiography is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease, and is not a medically acceptable replacement for other conventional screening tests within the standard of care such as treadmill stress testing. CT angiography is also not a medically acceptable substitute for coronary angiography, as CT angiography would not be able to accurately confirm or exclude important coronary obstruction. The use of CT angiography in the diagnosis and prognosis of coronary artery disease currently remains an experimental/investigational application of this technology. Therefore, I have determined that the requested diagnostic procedure is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.