Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Premature ventricular contractions (PVC's)

Treatment: Myocardial Perfusion Imaging (MPI)

The insurer denied coverage for Myocardial Perfusion Imaging (MPI). The denial was upheld.

This patient is a male with a history of palpitations, ablation, Premature Ventricular Contractions (PVC), and a normal echocardiogram. He developed shortness of breath (SOB), chest pain, and palpitations. On a specified date the patient presented for a Cardiology evaluation due to an increase in palpitations and premature ventricular contractions (PVCs). An exercise tolerance test (ETT) was performed but was considered non-diagnostic due to inadequate heart rate response due to beta blocker. A Holter monitor test revealed underlying sinus rhythm with symptomatic, frequent PVC's.  Myocardial perfusion imaging (MPI) stress testing is under review.

According to Wolk, M. J.,et al. (2014), "8. For certain indications, emphasis has been placed upon the patient's ability to exercise and achieve 85% of their age-predicted maximal heart rate (220 age). When the patient's ability to exercise is not explicitly stated, it should be assumed that the patient can exercise to a symptomatic endpoint or 85% of their age-predicted maximal heart rate. Similarly, it should be assumed that the electrocardiogram (ECG) is interpretable unless otherwise stated.

The mode of stress testing is assumed to be exercise (e.g., treadmill, bicycle) for patients able to exercise for the modalities for which some form of "stress" is required. For patients unable to exercise, it is assumed that pharmacological stress may be performed using the appropriate agent and/or with or without low level exercise. For CMR, it is assumed that vasodilator stress perfusion is the technique used."

Cremer, P., et al (2014) states, "Myocardial perfusion imaging (MPI) to diagnose coronary artery disease (CAD) is best performed in patients with intermediate pretest likelihood of disease; unfortunately, pretest likelihood is often overestimated, resulting in the inappropriate use of perfusion imaging. A good functional capacity often predicts low risk, and MPI for diagnosing CAD should be reserved for individuals with poor exercise capacity, abnormal resting electrocardiography, or an intermediate or high probability of CAD."

The health care plan acted reasonably and with sound medical judgment, as well as in the best interest of the patient.      

This patient presented with chest pain, palpitations, and SOB in a non-acute setting. There were no baseline ECG abnormalities that would preclude accurate interpretation during treadmill testing such as a left bundle branch block, paced rhythm, digoxin therapy, pre excitation, 1mm or greater baseline ST depression, or atrial fibrillation/flutter. There was also no past submaximal treadmill test, or previous negative or non-diagnostic treadmill test, in the setting of ongoing typical angina. The negative stress test on a specified date was for palpitations. There was no inability to ambulate on a treadmill. In the setting of this case the addition of imaging, such as SPECT, to standard treadmill testing has not been established as standard of care towards improved cardiac outcomes. Therefore, MPI stress testing is considered not medically necessary in this case.

Based on the above, the medical necessity for the Myocardial Perfusion Imaging (MPI) is not substantiated.  The insurer's denial is upheld.