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

Physician 1: The patient is a 45-year-old male with a strong family history of coronary artery disease, hyperlipidemia, and prior significant elevated liver function testing. He has been taking Lipitor. The patient has no record of chest discomfort and is currently taking aspirin and exetimibe. A recent stress echo showed no evidence of coronary ischemia. An EBCT scan was performed in August 2004 and the patient has requested reimbursement for the procedure. The Health Plan has denied the patients request on the basis that EBCT is considered investigational. Based on the records provided, the patient is asymptomatic with coronary risk factors of strong family history, elevated cholesterol, and a stress test with no ischemia. Guidelines for a coronary risk assessment and treatment have been developed and are continually updated by national expert panels. Currently, such panels do not recommend the routine use of EBCT. In addition, there is no evidence that EBCT provides incremental value above that which can be obtained from clinical risk profiles and conventional stress testing. Finally, in the case of this patient treatment of risk factors is not likely to change based on EBCT results as the patient is already taking aspirin and exetimibe, and statins are contraindicated secondary to a prior strong family history and low dose Lipitor. Lifestyle modification, diet, and exercise are encouraged regardless of EBCT results. Based upon the information set forth above, I have determined that the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 2: The patient is a 45-year-old male with a strong family history for premature coronary disease in both his father and a brother. Based upon the records provided, it appears that the patient underwent stress testing in 1997, 2001, and in 2002. In addition, there is a notation in the cardiologists records that the patient had undergone a recent negative stress echo. The patient had a history of liver dysfunction while on Lipitor, and an EBCT was apparently recommended to help determine if benefits outweigh the risks in regard to trying another statin medication in light of slightly elevated LDL cholesterol levels even while on Zetia. The patient indicated in a questionnaire that he was without symptoms of chest pain or shortness of breath. The patient has requested coverage for the EBCT at issue. The Health Plan has denied his request indicating that EBCT remains investigational. Review of the current medical literature indicates the efficacy of EBCT remains unproven. A medical review updated July 2004 and published in UpToDate concludes that EBCT should not be viewed independently, but in the context of more conventional risk assessments or risk factors in asymptomatic low or high-risk patients. The uncertainty surrounding EBCT was discussed later in the same article. The author stated, Still, the literature does not clearly define which asymptomatic individuals require or will benefit from EBCT screening. Based upon the information provided, a stress echo exam or even a determination of the patients Framingham risk score could have been utilized to assess the utility of additional trials of statin medication in this patient who appeared to have liver dysfunction after Lipitor. Therefore, I have determined the requested procedure was not likely to be more beneficial than any available standard treatment. The Health Plans denial should be upheld.Physician 3: The patient is a 45-year-old male with hyperlipidemia, strong family history of premature coronary risk, abnormal C reactive protein level, and aortic sclerosis. The patient also has a history of elevated liver functions on Lipitor therapy. As a male with the above risks, he is at an increased risk of cardiovascular events. The patient underwent an EBCT scan in August 2004. The Health Plan has denied coverage for the procedure at issue on the basis it is considered investigational. Although this patient has a negative functional stress test, his known risk factors (gender, family history, hyperlipidemia and abnormal C reactive protein) put him at increased risk for cardiovascular events. Given these known risk factors, the addition of an EBCT calcium score would not be expected to eliminate the need for lipid therapy. While the use of EBCT to establish levels of lipid lowering is promising, it is still an unproven use of this technology. Therefore, I have determined the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.