Coronary CT Angiography 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 61-year-old female enrollee has requested coronary CT angiography (CTA) for an evaluation her potential coronary artery disease (CAD). Findings: Two physician reviewers found that this patient has significant cardiac risk, symptoms of atypical chest discomfort and an equivocal stress test result. Under these circumstances, additional testing is reasonable and could include either invasive coronary angiography or noninvasive coronary CTA. Since the likelihood of coronary intervention is low based on primarily favorable stress test parameters, CTA was appropriate. In addition, the patient had at least an intermediate pretest probability of coronary ischemia and had an equivocal stress test result. The Appropriateness Criteria for coronary CTA support its use given these factors.

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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested a computed tomography (CT) angiogram for evaluation of his medical condition. Findings: Two physician reviewers found that if coronary ischemia is suspected then some form of stress testing is considered standard of care and most appropriate accepted practice in the medical community (Hendel et al). Coronary CT angiography defines coronary anatomy only, and does not assess the functional significance of any potential stenosis identified. Moreover, Miller and colleagues found that coronary CT angiography is less accurate compared to conventional angiography and may miss small branch vessel stenosis that could be identified on stress testing which may be responsible for the patient's symptoms.

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