Coronary Artery Disease denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: This patient is a 66-year-old female with coronary artery disease, diabetes and hypertension. She underwent cardiac revascularization in 2004 and became symptomatic again in April 2005 with shortness of breath and angina. The patient has requested authorization and coverage for enhanced external counterpulsation (EECP). The Health Plan has denied this request indicating the requested therapy is considered investigational. The most recent ACC/AHA practice guidelines from 2002 consider enhanced external pulsation (EECP) as a Class IIb therapy for the treatment of chronic stable angina in patients who are refractory to medical therapy who are not candidates for PTCA or surgical intervention. This means its usefulness/efficacy is less well established by evidence or opinion.

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting reimbursement for a stent and percutaneous transcatheter placement of drug eluting intracoronary stent done. The enrollee initially presented to his physician with complaints of chest pain on exertion. The left sided chest pain has been ongoing for the past days, and he had similar pains in past. The pain radiated to his left scapula and he has had recurrence of several episodes of chest discomfort with exertion. Findings the physician reviewer found that after a one to two min rest after onset of the pain, it resolves. He says that all episodes are under heavy exertion, backpack at high altitudes. He does not have a personal history of heart disease, but his father had coronary artery disease with a cardiac bypass. He had two routine visits and had no complaint of chest pain.

Where the denial was upheld

Physician #1: The patient is a 47-year-old male with non-Hodgkin’s 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.

Physician 1The patient is a 49-year-old male who has requested authorization for an electron beam computerized tomography (EBCT) heart scan to determine the significance of an indeterminate ECG stress test.The patient has hypertension and a positive family history of premature coronary artery disease (CAD). The submitted records do not address the presence/absence of any other risk factors. On 9/27/02, the patient underwent an EBCT scan. The total calcium score was zero. On 9/23/03, the patient underwent a Bruce Protocol stress test. He exercised 13 minutes (14.8 METs) to 105% of the maximum predicted heart rate for age. No symptoms were reported. A 2mm ST depression was reported as suggestive of myocardial ischemia. The ST depression onset time was not stated. Neither an ECG report nor description of the findings has been submitted.

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 coronary artery disease, then check the rights and deadlines that apply to your plan.