Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1:  The patient is a 56-year-old male with risk factors for coronary artery disease (CAD) including a family history of heart disease and hyperlipidemia. The documentation provided noted symptoms of palpitations, but no chest pain. His treating physician referred him for CT angiography (CTA). The Health Plan denied coverage for the diagnostic procedure on the basis that it is considered experimental/investigational.The 2006 appropriateness criteria do not as yet incorporate the routine use of CTA, as the incremental value of the technology has not yet been established. Current criteria for the use of CTA in the detection of coronary artery disease (CAD) indicates it is not appropriate in the asymptomatic (without chest pain syndrome) patient with low or moderate risk. Even for high risk, but asymptomatic patients, the appropriateness CTA still remains uncertain. Risk assessment in the general population is similar, and the criteria state it is either inappropriate or uncertain, for low/moderate or high risk individuals respectively. The records include no other factors that would that would establish a basis for the application of CTA. Anti-lipid therapy that the patient can tolerate is generally indicated for patients such as this one.Based upon the information set forth above, 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 56-year-old male with a family history of coronary disease and a personal history of high cholesterol and PVCs/palpitations. There is no documented history of chest discomfort contained in the record. Lipitor was prescribed for the patient but was later discontinued due to generalized soreness and an elevated CPK of 466. CT angiography (CTA) was preformed in March 2006 on the recommendation of the patients provider, and a request for reimbursement is pending. The Health Plan considers CTA an investigational procedure and has denied reimbursement.Based on the records provided, the patient had at least two risk factors for coronary disease, but no chest discomfort or other symptoms suggestive of an acute cardiac process. In this setting, there are guidelines established by national experts in the field of coronary disease, that provide diagnostic and treatment recommendations. These criteria are based on clinical indices and do not yet include or recommend the routine use of CTA. In addition, it is not clear that CTA provides incremental value with respect to outcome or treatment approach beyond that which can be obtained by clinical risk indices in combination with conventional stress testing when indicated. 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:  The patient is a 56-year-old male with hypertension and hyperlipidemia along with a family history of heart disease. His provider noted palpitations and/or PVCs in the clinical record. The patient was started on lipid therapy and CTA was recommended and the study was performed in March 2006. The patients request for reimbursement was denied by the Health Plan citing the experimental/investigation nature of the diagnostic procedure.CTA is not thus far, a generally accepted screening or confirmatory test for the diagnosis of coronary artery disease. It is not a medically accepted replacement for conventional screening tests such as treadmill stress testing or an appropriate substitute for coronary angiography. CTA would not be able to accurately confirm or exclude important coronary obstruction. The use of CTA in the diagnosis and prognosis of coronary artery disease remains an experimental/investigational application of this technology. Consequently, 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.