Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested CPT codes, 99215, 36415, 76977, 82270 X 3, 82365, 82397 x 122, 99000, 99001, 93720, 93922 x 2, 94010 x 2, A4649 x 4, A4556NU, A4617NU X 2, A4927NU, 99214, and 82365, for evaluation of her medical condition. Findings:  The physician reviewer found that with regard to CPT code 76977 (bone mass screening by ultrasound), this study was not medically necessary in a patient of this patients age without a history of hyperparathyroidism. In addition, there were no clinical indications for CPT code 82365 (infrared spectroscopy) based on the documentation provided. CPT code 82397 (chemoluminescence), is not within the standard of care in this particular setting and thus was not medically necessary. CPT code 93720 (body plethysmography) is indicated for patients who have air spaces within the lung that do not communicate with the bronchial tree. There was no indication for this study based on the patients presentation. Nor was there any indication for CPT code 93922 (evaluation of elasticity and blood flow) or CPT code 94010 (spirometry) based on the patients documented signs and symptoms at the time of presentation.  The other services at issue consist of CTs scans that were ordered for further evaluation of the patients abdominal, pelvic and chest complaints. The use of CT in this setting was not in accordance with generally accepted imaging guidelines. For instance, concerning the use of CT imaging for evaluation of the patients abdominal pain, most of the medical literature devoted to analyzing patterns of investigations for abdominal pain is limited to acute pain rather than chronic pain. The evaluation of the patient with abdominal pain begins first and foremost with the history and then the physical examination. The vast majority of cases of abdominal pain can be diagnosed with these two features and do not require CT imaging.Concerning the patients pelvic pain, after the history and physical examinations and laboratory testing is analyzed, the patient with pelvic pain may benefit from imaging studies. Clearly, gastrointestinal and renal sources of pain are important causes to consider in evaluating pelvic pain. Abdominal and pelvic ultrasounds are useful tests to look for obstruction in the biliary tree, the urinary system, and the female pelvic organs and are usually performed prior to CT scanning. They are sensitive and specific in their findings and do not expose the patient to the x-ray radiation of CT scans. With regard to the patients chest symptoms, there are many diseases of the lung. Common diseases include inflammatory, traumatic, developmental, infectious, and neoplastic etiologies. After the history and physical examinations, a chest x-ray typically precedes the CT scan in the work-up of a chest problem. The CT scan of the chest is a useful diagnostic tool for evaluating a solitary lung nodule, multiple lung nodules, diffuse infiltrating lung disease, and pulmonary embolisms. In nearly all cases of these maladies, there are significant findings that make CT imaging a reasonable next step. In this case, clinical indication for CT scan was not present. In summary, the CPT codes requested are not medically necessary in this patients particular clinical situation.