CT Angiography denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested gastric emptying study, a computed tomography (CT) angiography and a fecal microbiota transplant for treatment of the enrollee, who has a history of abdominal pain. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services. This patient has symptoms consistent with gastroparesis, but also consistent with other diseases.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the computed tomography (CT) angiography (CPT 75574). Findings: The physician reviewer found that as noted by the American College of Cardiology Foundation (ACCF), coronary CTA with contrast is often used to evaluate possible anomalous coronary arteries. Studies found that “cardiac CTA provides excellent spatial and temporal resolution, allowing accurate anatomical assessment of these anomalies.” Moreover, if the contrast coronary CTA was not done, another study such as a cardiac catheterization would have been indicated. Given this support, the CTA (CPT 75574) performed was medically necessary for further evaluation of this patient’s medical condition.

Where the denial was upheld

Physician 1: The patient is a 57-year-old woman with hyperlipidemia and complaints of chest pain and shortness of breath. In November of 2000 she underwent a cardiac catheterization, which showed “Normal left ventrical function. No angiographic evidence for significant epicardial coronary artery disease. Small distal left anterior descending either normal variant and a small eddy, although cannot rule out diffuse concentric distal left anterior descending disease to account for the patient’s apical ischemia and atypical chest discomfort.” An adverse reaction to the catheter/anesthesia is not found in the dictated report.In March 2005 she underwent a stress myoview SPECT scan. She had no ischemia. The patient is unable to tolerate statins for hyperlipidemia. Per the submitted records, she is not on cardiac medications such as beta-blocker or nitrate.

Physician 1: The patient is a 56-year-old woman who has a history of hyperlipidemia and smoking. She has been diagnosed with chest pain syndrome, she has “intermittent VEA” (ventricular ectopic activity) and she is treated with flecainide for “variable palpitations.” The specific arrhythmia that is being treated with flecainide was not described nor is the precise diagnosis associated with the palpitations. A stress test or perfusion study is not included in the documentation. The September 2006 provider’s note indicated the EKG was “NSR, NL” or normal. The provider also noted the patient did not have recurrent chest pain, but had intermittent VEA and chest pain with VEA. The provider indicated that CAD should be ruled out and referred the patient for CT angiography (CTA).

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