Appeal type: Experimental/Investigational
Decision: Upheld

Physician #1:  The patient is a 47-year-old male with non-Hodgkins lymphoma. He has been treated with radiation and cardiotoxic chemotherapy. He developed exertional chest pain. An echo stress test was low risk positive. The provider has recommended CT coronary angiography. The Health Plan has denied authorization for the procedure on the basis that it is investigational in nature.The consulting cardiologist indicated the patient needs further evaluation. The patient has a Class IIb indication for angiography; however, the uncertainty caused by complicating cardiotoxic chemotherapy increases the usefulness of the procedure in this patient.CT coronary angiography is an emerging technology. Performed on 64-slice scanners in centers of excellence it has been shown to be equivalent to angiography in detecting proximal to mid coronary artery stenosis. It is superior to conventional angiography in that it is non-invasive.In the case of this patient, he is likely to derive more benefit from CT coronary angiography because of the risk/benefit ratio. In this clinical setting, CT coronary angiography is the most appropriate choice. Accordingly, I have determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician #2:  The patient is a 47-year-old man with a history of lymphoma and radiation treatment. He has several risk factors for coronary artery disease (CAD) including smoking, family history, and hyperlipidemia.  His CRP is elevated. He was referred for cardiac evaluation because of exertional chest pain. The patient underwent non-invasive workup with a stress echo; the results were abnormal. The report states ST-T changes consisting of 1.5 mm ST Lateral depression. The stress echo study was abnormal due to LV function. EF does not increase. There is apical septal hypokinesis. The final stress echo conclusion is abnormal. The patients treating cardiologist states invasive testing (angiography) would be too risky. Therefore, he has recommended a coronary CT angiography (CTA). The Health Plan has denied coverage for this procedure citing a lack of proven efficacy.Despite some favorable small studies, and increasing clinical use, CTA is only variably accepted as a current standard over traditional conventional invasive coronary angiography. Many feel that there is insufficient evidence that CTA is as accurate as conventional invasive coronary angiography for screening or detection of CAD indications. According to available evidence-based guidelines, conventional invasive coronary angiography is still considered the current standard for assessment of coronary arteries.The most recent AHA Scientific Statement (Circulation, 2005) continues to recommend the standard workup towards conventional angiography when indicated, rather than CTA as an intermediate step. CTA is not currently recommended as an intermediate or confirmatory step prior to traditional cardiac catheterizaton/angiography. It is slowly being increasingly used, without large trials, in equivocal cases, case involving coronary anomalies and coronary artery bypass grafts, and those cases with difficult anatomy to access by catheterization. In the case of this patient, medical treatment and/or a diagnostic cardiac catheterization and potential revascularization is the next appropriate clinical step to be considered. A CTA in this setting (of exertional chest pain) does not add much given the high probability of CAD. If the CTA shows a high-grade lesion, then diagnostic catheterization is still indicated. If the CTA shows non-critical disease, the patient will still require medical treatment for primary or secondary CAD prevention and/or diagnostic catheterization. It is important to note that cardiac catheterization, and not the CTA, is the necessary test prior to revascularization. If the patient is unable to undergo catheterization and subsequent revascularization, then the alternative is medical therapy for ischemia. If his prior history of radition therapy and lymphoma make cardiac catheterization and angiography too risky, then medical therapy maybe the best and only alternative. Currently, without large cohort studies or new published guidelines from the AHA, ACC or USTSP, there is insufficient evidence or recommendations supporting the use of CTA in this setting. Based upon the information set forth above, I have determined that the requested 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 47-year-old male with exertional chest pain and an abnormal stress echocardiogram showing ischemic ST changes by EKG as well as segmental wall motion abnormalities and non-increase in LV function with exercise also consistent with ischemia. The patient has requested coronary CT angiography (CTA) for further evaluation of coronary artery disease. The Health Plan has denied this request on the basis that there is insufficient peer-reviewed evidence demonstrating CTA is useful in this setting.Coronary CT angiography (CTA) is not a medically approved or 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. CTA is also not a medically acceptable substitute for coronary angiography, as CTA would not be able to accurately confirm or exclude important coronary obstruction. The use of CTA in the diagnosis and prognosis of coronary disease currently remains an experimental/investigational application of this technology. As such, the use of CTA in this case is not likely to be more beneficial for the patient than available medically accepted treatment. If the patient is not a candidate for cardiac catheterization based on his other medical conditions, surgical or percutaneous revascularization would also be precluded, in which case medical therapy with no further testing would be appropriate unless the patient becomes a candidate for cardiac catheterization and revascularization procedures in the future.Based upon the information set forth above, I have determined that the requested 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.