Atherosclerotic Cardiovascular Disease denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee requested reimbursement for CT heart calcium scoring scan without contrast (CPT code 75571). She saw her cardiologist for follow up of premature atrial contractions (PACs). Her atherosclerotic cardiovascular disease (ASCVD) risk was 9.8%. The cardiologist ordered computed tomography (CT) heart calcium scoring without contrast (CPT code 75571). The total coronary artery calcium scoring was 17, placing the enrollee at the 30th percentile for asymptomatic females of this age. According to the medical literature, Framingham risk score (FRS) of 10-year atherosclerotic cardiovascular disease (ASCVD) risk less than 10% is considered low risk. However, studies have shown the predictive power of cardiovascular risk factors decreases with age, partly because of selective survival and the influence of co-morbidities on risk factor levels.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for Repatha for the treatment of his atherosclerotic cardiovascular disease (ASCVD).With elevated triglyceride as a risk enhancer, treatment guidelines published by the American Heart Association (AHA) and American College of Cardiology (ACC) support lipid-lowering therapy aiming for a 30- 49% reduction in low-density lipoprotein-cholesterol (LDL-C). A randomized controlled trial demonstrated the efficacy of PCSK9 inhibitors such as Repatha that resulted in significant reductions in LDL-C and cardiovascular events in patients with existing ASCVD. However, the study showed superior LDL-C lowering with the PCSK9 inhibitor alirocumab over ezetimibe specifically in statin-intolerant, moderate to high cardiovascular-risk patients.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Praluent for treatment of the enrollee who has a history of chronic lipid issues. Findings: The physician reviewer found that The American College of Cardiology (ACC) has developed an expert consensus decision pathway (2016) regarding the role of non-statin therapies for LDL cholesterol lowering for management of atherosclerotic cardiovascular disease risk (ASCVD). There are several points, which are relevant to this case. The 2013 ACC/American Heart Association cholesterol guideline identified four major statin benefit groups for atherosclerotic cardiovascular disease risk reduction.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for apolipoprotein B (ApoB) testing. An elevated ApoB) level is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD). In a multi-society guideline on the management of blood cholesterol, researchers report that ApoB is a “risk enhancer” when coupled with other findings such as a family history of premature ASCVD or familial hypercholesterolemia. An elevated ApoB level is also relevant in patients with hypertriglyceridemia, where it may indicate atherogenic potential, and also possibly in patients who are at an intermediate risk for ASCVD. In patients without these findings or conditions, as in this case, current treatment guidelines or risk calculators do not recommend or support the routine measurement of ApoB levels.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving atherosclerotic cardiovascular disease, then check the rights and deadlines that apply to your plan.