Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the noninvasive estimated coronary fractional flow reserve 
(FFR) derived from coronary computed tomography angiography data using computation fluid dynamics 
physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; 
analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated FFR model 
provided on March 9, 2022. 
 
You asked the Plan to pay for the noninvasive estimated coronary fractional flow reserve (FFR) derived from 
coronary computed tomography angiography data using computation fluid dynamics physiologic simulation 
software analysis of functional data to assess the severity of coronary artery disease; analysis of fluid dynamics 
and simulated maximal coronary hyperemia, and generation of estimated FFR model. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services rendered are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that FFR computed tomography technology is only covered for certain indications.
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the noninvasive estimated coronary 
fractional flow reserve (FFR) derived from coronary computed tomography angiography data using 
computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity 
of coronary artery disease; analysis of fluid dynamics and simulated maximal coronary hyperemia, and 
generation of estimated FFR model. Our reviewer says that the documentation does not support that the 
services rendered were medically reasonable or necessary. Our physician reviewer found there was no 
documentation of prior coronary computed tomography angiography. The review has determined that the 
enrollee does not meet the following criteria for the services rendered: a. Intermediate-risk patients with acute 
or stable chest pain with no known history coronary artery stenosis with finding of 40-90% in proximal or 
middle coronary artery on CCTA1 OR b. Intermediate risk patients with acute chest pain and known non-
obstructive (less than 50%) CAD coronary artery stenosis with finding of 40-90% stenosis in proximal or 
middle coronary artery on CCTA1 OR c. Stable non-obstructive coronary artery disease (less than 50% 
stenosis) with persistent symptoms requiring further test, and finding of 40-90% stenosis on CCTA1 and not in 
conjunction with stress testing (unless CCTA was not sufficient quality for FFRCT, and an alternative study 
needed). Therefore, the enrollee did not meet criteria for the services rendered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the noninvasive estimated coronary fractional flow reserve (FFR) derived from 
coronary computed tomography angiography data using computation fluid dynamics physiologic simulation 
software analysis of functional data to assess the severity of coronary artery disease; analysis of fluid dynamics 
and simulated maximal coronary hyperemia, and generation of estimated FFR model have not been met. 

Therefore, we decided that the Plan does not have to pay for the noninvasive estimated coronary fractional flow 
reserve (FFR) derived from coronary computed tomography angiography data using computation fluid 
dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery 
disease; analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated 
FFR model provided on March 9, 2022.