CAD: when insurers say no, reviewers often say yes

Where the denial was overturned

Physician 1: The patient is a 62-year-old man with symptomatic paroxysmal atrial fibrillation. His condition was refractory to multiple medications. The treated condition was not coronary artery disease, but atrial fibrillation. The patient’s provider recommended he undergo pulmonary vein isolation. The treating electrophysiologist ordered electron beam angiography to assess the pulmonary veins before and after the procedure. The Health Plan has denied coverage for the electron beam angiographies on the basis the services are experimental. Electron beam angiography is a technique without a comparable equivalent. Electron beam technology provides a three-dimensional image, which is superior to the two-dimensional imaging provided by conventional, invasive angiography. Electron beam angiography was a component of the pulmonary vein isolation procedure approved for this patient.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the wound therapy pump vacuum and wound dressing sets/equipment. Findings: The physician reviewer found that in the medical literature, a study noted that negative pressure wound therapy (NPWT) following greater saphenous vein (GSV) harvest is “safe, well tolerated and improves postoperative recovery with prolonged impact on mobility at six weeks.” Another study reported that the VAC can effectively reduce postoperative complications, such as lymphedema, incision infection, wound dehiscence, and skin flap necrosis in CABG patients who underwent great saphenous veins harvesting. Overall, there is adequate data in the scientific data supporting NPWT for surgical dehiscence.

Where the denial was upheld

Physician 1: The patient is a 50-year-old female with a history of hyperlipidemia and low levels of HDL treated with gemfibrozil and Pravachol. She had a baseline EBCT in 2003 and a second imaging study in June 2005. The Health Plan denied the patient’s request for reimbursement of the follow-up study based upon their determination that EBCT is considered experimental/ investigational for evaluation of coronary artery disease. In adults at low risk for coronary heart disease (CHD) events, the United States Preventive Services Task Force (USPSTF) now recommends against routine screening for either the presence of severe coronary artery stenosis (CAS) or the prediction of CHD events with resting electrocardiography (ECG), exercise treadmill test (ETT), or electron-beam computed tomography (EBCT) scanning for coronary calcium.

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.

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 cad was denied, the published record says the denial is worth fighting.