Coronary Computed Tomography Angiography denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the coronary computed tomography (CT) scan for evaluation of the enrollee’s chest pain and lightheadedness. Findings: The physician reviewer found that based on the records provided this patient presented with ongoing atypical chest discomfort that has an exertional component, is reproduced on treadmill exercise and is associated with T-wave inversions on electrocardiography. In this circumstance of ongoing atypical symptoms of uncertain cause, evaluation for rare conditions such as anomalous coronary artery is reasonable, appropriate, and considered standard accepted practice in the medical community. Current guidelines consider coronary CT angiography an appropriate test to evaluate for coronary anomaly and has a preference over conventional angiography since it is less invasive with fewer risks.

A 57-year-old male enrollee has requested coronary computed tomography angiography for evaluation of himself, who has a history of neck pain and an abnormal electrocardiogram. Findings: Three physician reviewers found that the services at issue were likely to have been of greater benefit than other methods of evaluation. This patient had significant coronary risk and ongoing atypical chest discomfort in association with prior unremarkable stress testing. In this clinical setting, additional cardiac evaluation was indicated. Current guidelines endorsed by several national organizations consider coronary computed tomography scanning to be medically appropriate in patients with continued symptoms and prior normal exercise stress testing. The current medical evidence supports the superior efficacy of coronary computed tomography angiography for the evaluation of this patient.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for coronary computed tomography angiography (CCTA) for evaluation of the enrollee, who has aortic valve stenosis.Findings: The two of the physician reviewers found that This patient had increased coronary risk and severe asymptomatic aortic valve stenosis with normal left ventricular systolic function. In this circumstance of no documented cardiac symptoms and normal left ventricular function, there is no accepted indication for aortic valve replacement according to current guidelines endorsed by several national organizations. Therefore, coronary angiography was not indicated.

A 50-year-old male has requested coverage for a past coronary computed tomography (CT) angiography with 3D imaging for evaluation of his atypical chest pain with abnormal stress treadmill. Findings: Two physician reviewers found that the patient has a history of hyperlipidemia, obesity, and psoriasis. He presented with non-exertional chest pressure and left arm pain associated with dyspnea. An exercise stress test did not provoke chest discomfort but he developed 1 to 1.6mm horizontal inferolateral ST depression at peak exercise that became downsloping in recovery. Invasive coronary angiography was recommended, but the patient was not agreeable to that procedure. Coronary computed tomography (CT) angiography was then performed and revealed a left ventricular ejection fraction of 0.68 as well as 50% stenosis of the mid left anterior descending coronary artery.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Coronary Computed Tomography Angiographywhen you appeal: reviewers routinely find that denials like yours didn’t hold up.