Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CTA scan for the enrollee.
You asked the Plan to pre-approve a CTA scan. You say that the requested CTA scan is medically necessary.
The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for CT angiography
(CTA) of the chest. The Maximus Physician Reviewer determined that the requested CTA was considered
medically reasonable and necessary in this case. The Plan requested a reopen and argues that there was no
reason given in the office notes explaining why the chest imaging was necessary. The Plan notes that prior
imaging of the chest from June 2020, September 2020 and March 2021 were all stable and without concerning
findings in the chest. Additionally, the enrollee was completely asymptomatic. The Plan states that if there was
documented concern for aneurysm, a chest x-ray or echo could be considered as initial imaging to minimize
excessive radiation exposure to the member. Without known or changing chest pathology, prior chest surgery,
concerning symptoms, or details as to how the Chest CTA would change management of this member with
known abdominal vascular disease, the CTA Chest is not reasonable. A Chest CTA subjects a person to
significant radiation. The Plan concludes that, given the number of CT and CTA's the enrollee has had in the
past, "continuing to screen his chest without new symptoms, findings, or clear plan for a change in
management is unnecessary and potentially harmful."
Review the medical records show the enrollee is an 80-year-old man with extensive vascular disease, including
an abdominal aortic aneurysm, a femoral pseudoaneurysm, a saccular aneurysm of the proper hepatic artery,
and bilateral internal carotid artery stenosis. The enrollee underwent endovascular repair of an abdominal aortic
aneurysm June 24, 2020. On June 30, 2020, the enrollee underwent repair of a right femoral pseudoaneurysm.
A CTA of the chest, abdomen, and pelvis on September 14, 2020, showed that the ascending aorta was again
normal. The arch vessels were patent without high-grade stenosis. An atherosclerotic irregularity with a small
irregular plaque in the proximal descending thoracic aorta was stable. The descending aorta was normal in
caliber, and patent without high-grade stenosis. A CTA of the abdomen on March 10, 2021, revealed a stable
widely patent infrarenal abdominal aortic endograft with a type II endovascular leak which was still present.
The scan also showed a stable saccular aneurysm of the proper hepatic artery measuring up to 7 mm.
On March 23, 2021, the enrollee complained of bilateral lower extremity pain and burning. The plan was to
continue to monitor the enrollee with a CTA of the chest, abdomen, and pelvis in 6 months.
Our Medical Director has concluded that the Plan is correct in this case. There is insufficient documentation to
support that a CTA of the chest was medically reasonable and necessary for the enrollee in this case. The
enrollee did not have a thoracic aortic aneurysm on previous imaging. The enrollee was not reporting chest
symptoms. Previous CTA imaging of the thoracic aorta documented that the atherosclerotic irregularity with
irregular plaque was stable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve a computed tomography angiography (CTA) scan for the enrollee.