Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1:  The patient is a 62-year-old male with a history of dyspnea on exertion who underwent treadmill stress testing.  EGK changes were noted during the test and were suggestive of ischemia. The documentation also indicates normal cholesterol levels with a slightly low HDL and a slightly high LDL. The patients treating physician referred him for a PET rubidium scan for further work up of his condition. The Health Plan denied coverage for the diagnostic procedure on the basis that it is considered experimental/investigational.The most recent ACC/AHA guidelines recommend SPECT imaging (Class I) for the diagnosis of patients with an intermediate likelihood of coronary artery disease (CAD) The guidelines indicate that PET is appropriate (Class IIa) only if the SPECT study has been found equivocal, the patient cannot exercise, or the patient has a left bundle branch block (LBBB) or a paced rhythm. In a case such as this one, the usual next step in the work up of CAD would be to proceed with a perfusion SPECT study and the record does include such a  study. While the use of PET is not experimental per se, its use as a second step in the workup of dyspnea is not consistent with current standards of practice. The ACC/AHA guidelines would support a treadmill SPECT as the next step in the patients diagnostic work up. In consideration of current ACC/AHA guidelines, I have determined that the diagnostic procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2:  The patient is a 62-year-old male with dyspnea on exertion who underwent treadmill exercise stress testing. The patient was able to exercise for over six minutes and achieved 96% of the maximum predicted heart rate; however the EKG results were consistent with ischemia. The patients provider referred him for an adenosine PET rubidium scan for further evaluation, which was performed in December 2005. The patients request for reimbursement for the diagnostic procedure was denied by the Health Plan citing the experimental nature of PET scanning in this clinical context.According to the most recent ACC/AHA guidelines for the clinical use of radionuclide imaging, SPECT imaging is indicated for patients with this symptomology (Class I). Although PET imaging has been shown to be superior to SPECT in the detection of myocardial viability in areas of scar or poor function, that was not the reason for its use in this case. There have been no head-to-head comparison studies between PET and SPECT imaging which demonstrate that PET is superior in the detection of coronary artery disease. The standard clinical practice in a case such as this one would be to obtain SPECT imaging prior to PET imaging. Therefore, I have determined that the diagnostic procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3:  This patient is a 62-year-old male who was experiencing dyspnea on exertion. He had an abnormal stress EKG and was referred for a PET rubidium scan. The results of the December 2005 PET scan were within normal limits and the patients ejection fraction was also normal. The patients request for reimbursement for the PET rubidium scan performed on the recommendation of his provider is pending. The Health Plan considers PET scan an investigational procedure in this setting and has denied reimbursement.PET is typically necessary for patients with an intermediate risk of coronary disease in the range of 25% to 75% probability. This is generally a patient that has had a myocardial infarction or a stroke. Additionally, a SPECT scan can provide adequate, and in most cases equivalent, diagnostic information. In this case, SPECT imaging would have been the appropriate procedure for the next step in the patients work up for coronary disease. As such, I have determined that the diagnostic procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.