Angina: when insurers say no, reviewers often say yes

Where the denial was overturned

A 41-year-old male enrollee has requested authorization and coverage for a computed tomography (CT) angiogram of the coronary arteries for evaluation of the enrollee’s chest tightness and irregular heartbeat. Findings: Two physician reviewers found that the patient has hypercholesterolemia and sought care from a cardiologist due to persistent and typical chest pain. He was evaluated in two years prior with a stress echocardiogram (ECHO), which was normal without evidence of myocardial ischemia. Due to persistent symptoms of angina, and to avoid an invasive coronary angiogram, a CT coronary angiogram was ordered to rule out obstructive coronary artery disease. The Health Plan ruled his coronary computed tomography angiogram (CTA) as investigational.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left heart cardiac catheterization and heart artery ventricle angiography. The records provided for review document that this patient has several risk factors for cardiovascular disease. She has typical and atypical chest pain symptoms and nuclear stress findings reported as positive for anterior ischemia. She was started on medical therapy without substantial improvement in her symptoms. She has described exertional and rest symptoms as well as medication side effects limiting treatment options. This patient meets the American Heart Association (AHA) and American College of Cardiology Foundation (ACCF) appropriate use criteria for cardiac catheterization and coronary angiography as an intermediate risk patient with persistent and life-limiting symptoms despite medical therapy.

Where the denial was upheld

Physician 1The patient is a 62-year-old male with a history of coronary artery disease and angina. He underwent coronary artery bypass grafting in 1988 and an angioplasty with cardiac stent placement in 1994. The patient reported experiencing chest pain in July 2004. An abnormal thallium scan showed midlateral wall ischemia. The patient’s provider recommended enhanced external counterpulsation (EECP). The Health Plan has denied authorization and coverage for EECP on the basis it is considered experimental for treatment of the patient’s medical condition.The patient has known coronary disease and angina. However, based on the submitted records of the stress test performed on 7/27/04, the patient is able to walk 8.03 on a Bruce Protocol without chest discomfort or ST changes and with appropriate augmentation of heart rate and blood pressure.

Physician 1: The patient is a 62-year-old male who is reported to have small vessel disease, not amenable to revascularization. The cardiac catheterization describing the anatomy is not in the documentation provided. His angina is atypical, occurring at rest, but it is reported that he does not generally get chest discomfort while doing exercises. He is only on a beta-blocker for angina. He is also able to use an easy-glider for about half-an-hour a day. The patient’s provider has requested authorization for enhanced external counterpulsation (EECP) therapy, which has been denied by the Health Plan.The most recent American Heart Association (AHA) guidelines in 2002 list EECP as a class IIb therapy or “usefulness/efficacy is less well established by evidence/opinion” (Gibbons, et. al.).

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for angina was denied, the published record says the denial is worth fighting.