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

The patient is a 54-year-old male who has requested reimbursement for EECP, hyperbaric oxygen, and chelation therapy for treatment of coronary artery disease. The records indicate the patient was treated for hypertension, diabetes type II, dyslipidemia, and hypogonadism. The submitted records do not include detailed information regarding the patients coronary artery disease. Reference is made to an abnormal stress test and coronary angiogram prior to December 2002. A stress test in January 2003 indicates the patient exercised 10 minutes to a heart rate of 148. The test was terminated because of fatigue. No chest pain was reported. ST depression was detected in the post exercise period. EECP therapy commenced three days later in January 2003. The subsequent medical records indicate the patient did not complain of chest pain. He was not treated with anti-angina medication. The Health Plan has denied reimbursement for EECP, hyperbaric oxygen therapy and chelation therapy on the basis the services were not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. With regard to EECP, in 2002 the American College of Cardiology and the American Medical Association issued a joint statement indicating the procedure was investigational.  In 1999, HCFA approved EECP as a reasonable and necessary treatment for patients suffering from stable angina pectoris refractory to medical and/or surgical therapy. HCFA states coverage of this therapy is provided for patients who have been diagnosed with disabling angina (Class II or Class IV, CCSF score or equivalent of classification), who in the opinion of a cardiologist or cardiothoracic surgeon are not readily amenable to surgical intervention. In the case of this patient there is no documentation of angina pectoris. The patient has not submitted documentation of medical or surgical management for angina pectoris. Objective testing indicates he did not meet medical necessity criteria for treatment.Regarding hyperbaric oxygen therapy, there is no body of medical literature supporting the use of hyperbaric oxygen therapy for the treatment of symptomatic or asymptomatic coronary artery disease. The American College of Cardiology and the American Heart Association have not published guidelines for the use of hyperbaric oxygen therapy in coronary artery disease. This treatment has not been established as effective and therefore, was not medically indicated in this patients management.Furthermore, regarding chelation therapy, position statements by the American College of Cardiology and the American Medical Association conclude there is insufficient scientific evidence to justify the application of chelation therapy for atherosclerosis on a clinical basis. At the present time, there is insufficient evidence chelation therapy is effective for atherosclerosis. As such, use of chelation therapy for treatment of this patient was not medically necessary.As set forth above, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.