Hypercholesterolemia denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a cardiac computed tomography (CT) and angiography. Coronary CT angiography is a quick, non-invasive test utilizing a specialized CT scanner to obtain high-resolution three-dimensional images of the coronary arteries. A coronary CT angiography allows the provider to see whether or not plaque has developed in the coronary arteries and whether plaque had caused stenosis, a narrowing of arteries that might cause symptoms or increase the patient’s risk of a future heart attack or death related to heart issues. In this case, the patient falls into the asymptomatic category. One set of medical guidelines state that it may be appropriate to perform CT angiography for selected asymptomatic high-risk individuals, especially for those who have a higher likelihood of having a large amount of non-calcified plaque.

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.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollee’s hypercholesterolemia. Findings: The physician reviewer found that the physician reviewer found that this patient presented with increased coronary risk. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations.

The patient is a 54-year-old female with rheumatoid arthritis, apparently being managed by both her internist and her rheumatologist. She is receiving a regimen of Enbrel, methotrexate, Plaquenil, Celebrex, and folic acid supplements for control of her arthritis. The records imply that the patient is doing well enough that she is able to continue working as a physical therapist. The patient has hypercholesterolemia. The patient’s provider has recommended Zetia over statin drugs because Zetia has a better probability of less liver toxicity than statin drugs. It is stated that the patient is following appropriate dietary measures, but her activity limitations prevent better non-pharmacologic control of her lipids; the degree of activity limitation is unclear from the records provided.

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 hypercholesterolemia, then check the rights and deadlines that apply to your plan.