Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve myocardial perfusion imaging, planar (including qualitative or 
quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when 
performed); single study, at rest or stress (exercise or pharmacologic) (78453). 
 
You asked the Plan to pre-approve myocardial perfusion imaging. You say that the enrollee has a life-
threatening situation of ectasia of the ascended thoracic aorta with severe coronary artery atherosclerotic 
calcification. The more the enrollee must wait, the more severe the aneurism can be, and it can burst at any 
time causing death. The Plan denied your request. The Plan says that the records do not show that the enrollee 
has any symptoms requiring emergent stress testing or any inability to perform vigorous exercise. The enrollee 
has congestive heart failure and known coronary artery disease. The request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 pre-approve myocardial perfusion imaging. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the review indicates that the enrollee has congestive heart failure and known 
coronary artery disease. She had a CT scan of the chest on May 10, 2022, that showed "severe coronary artery 
atherosclerotic calcification." At her doctor's visit on January 23, 2023, she denied any symptoms relating to 
these findings, including no chest pain, shortness of breath, or shortness of breath with exertion. The enrollee 
meets the LCD criteria, which states, patients with disease conditions associated with CAD (e.g., 
atherosclerotic abdominal aortic aneurysm, peripheral vascular disease, carotid artery disease, chronic renal 
failure) with no stress testing evaluation performed within the preceding 2 years and who are able to exercise. 
The review has determined that the requested imaging is medically necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging have been met. Therefore, we decided that the 
Plan has to pre-approve myocardial perfusion imaging, planar (including qualitative or quantitative wall 
motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single 
study, at rest or stress (exercise or pharmacologic) (78453).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.