Electron Beam Computed Tomography denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for electron beam computed tomography (EBCT). Coronary artery calcification has been shown to add incremental benefit to traditional risk prediction models to assess for risk of coronary artery disease. On review of the available documentation, this patient has hyperlipidemia with a 10-year atherosclerotic cardiovascular disease (ASCVD) risk of about 7.5%. Based on the American College of Cardiology (ACC) and American Heart Association (AHA) guidelines, the patient should be treated with a moderate to high dose statin. However, the provider noted that the patient has been unable to tolerate treatment with statins. The patient’s cholesterol is rising despite eating a vegetarian diet and attending Weight Watchers.

Where the denial was upheld

Physician 1: The patient is a 50-year-old female with a history of hyperlipidemia and low levels of HDL treated with gemfibrozil and Pravachol. She had a baseline EBCT in 2003 and a second imaging study in June 2005. The Health Plan denied the patient’s request for reimbursement of the follow-up study based upon their determination that EBCT is considered experimental/ investigational for evaluation of coronary artery disease. In adults at low risk for coronary heart disease (CHD) events, the United States Preventive Services Task Force (USPSTF) now recommends against routine screening for either the presence of severe coronary artery stenosis (CAS) or the prediction of CHD events with resting electrocardiography (ECG), exercise treadmill test (ETT), or electron-beam computed tomography (EBCT) scanning for coronary calcium.

Physician 1: The enrollee is a 60-year-old woman who may have chest pain syndrome. Her cholesterol is elevated to 221, but with a favorable ratio of HDL to LDL (HDL= 83, LDL= 110). The patient’s only reported risk factors are that is 60-year-old and apparently has family history of coronary artery disease. Documentation of other risk factors (smoking, diabetes and hypertension) are not provided.EBCT is not recommended as a general population screening test for coronary artery disease by the ACC or by the USPSTF guidelines. The standard of care would be to work up her chest pain with a stress test (treadmill) or a perfusion stress test (if EKG is abnormal). In symptomatic women with an intermediate likelihood of coronary artery disease, either an exercise treadmill test or an exercise echocardiogram is appropriate for initial screening.

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 Electron Beam Computed Tomography, then check the rights and deadlines that apply to your plan.