Appeal type: Experimental/Investigational
Decision: Upheld

Physician #1:  The patient is a 64-year-old male with a reported history of 50% blockage on a prior angiography. An EBCT performed in January 2005 was abnormal, showing a high level of calcification (683). The patient has risk factors of being an ex-smoker and having hyperlipidemia. A request has been made for authorization and coverage for a CT angiography. The Health Plan indicates CT angiography is considered investigational and therefore is not a covered benefit.Contrast-enhanced cardiac CT angiography involves the use of intravenously administered contrast material to obtain detailed images of the blood vessels of the heart. It is actively being investigated as an alternative to conventional invasive coronary angiography for evaluating coronary artery disease, coronary artery bypass grafts, and coronary artery anomalies.Some studies with small groups of patients have found non-invasive CT angiography is reliable and accurate. Despite these favorable small studies and emerging widespread clinical use, CT angiography is only variably accepted as a current standard over traditional conventional invasive coronary angiography, which is still considered the current standard for assessment of coronary arteries. The most recent AHA Scientific Statement continues to recommend the standard workup with stress perfusion studies towards conventional angiography, rather than CT angiography as an intermediate step.The most appropriate test in cases such as this where the calcium score is greater than 400 would normally be a stress perfusion study. If the patient has significant ischemia, then angiography towards revascularization should be considered. Treatment of secondary risks factors such as hyperlipidemia would be treated the same regardless. In any event, CT angiography is not likely to be of clinical value in this setting and is not medically indicated.Based upon the information set forth above, I have determined that the requested diagnostic procedure is 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 64-year-old asymptomatic male with hypercholesterolemia who is requesting authorization and coverage for CT angiography for the detection and evaluation of coronary disease. The patients provider indicates the patient had 50% blockage on a 2004 angiography. The Health Plan has denied authorization for CT angiography on the basis that it is considered investigational for evaluation of coronary artery disease.CT angiography is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease, and is not a medically acceptable replacement for other conventional screening tests within the standard of care such as treadmill stress testing. CT angiography is also not a medically acceptable substitute for coronary angiography, as CT angiography would not be able to accurately confirm or exclude important coronary obstruction. The use of CT angiography in the diagnosis and prognosis of coronary disease currently remains an unproven application of this technology. Therefore, I have determined that the requested diagnostic procedure is 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:  The patient is a 64-year-old male who has been identified as being at risk for coronary artery disease (CAD) based on past tobacco use, family history of CAD, treatment for dyslipidemia and elevated coronary calcium score. He was identified as having coronary artery disease by angiography in 2004. There is no documentation of angina or abnormal stress testing. A request has been made for authorization and coverage for a CT angiography. The Health Plan has denied this request citing a lack of peer-reviewed evidence supporting this technology.CT angiography is an investigational test that has not been proven to be more beneficial than conventional coronary angiography. Its principal advantage is that the procedure is non-invasive. CT angiography may be vitiated by a high calcium burden as seen in this patient. CT angiography may be superior to conventional angiography in a patient with a contraindication to conventional coronary angiography or in a patient with atypical symptoms and equivocal stress testing needing exclusion of CAD to avoid invasive testing.This patient has an ACC/AHA Class III indication for coronary angiography. Therefore, CT coronary angiography is not an acceptable substitute for the conventional angiography, a test that in and of itself is not indicated in this patient. Therefore, I have determined that the requested diagnostic procedure is 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.