Stent denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting reimbursement for a stent and percutaneous transcatheter placement of drug eluting intracoronary stent done. The enrollee initially presented to his physician with complaints of chest pain on exertion. The left sided chest pain has been ongoing for the past days, and he had similar pains in past. The pain radiated to his left scapula and he has had recurrence of several episodes of chest discomfort with exertion. Findings the physician reviewer found that after a one to two min rest after onset of the pain, it resolves. He says that all episodes are under heavy exertion, backpack at high altitudes. He does not have a personal history of heart disease, but his father had coronary artery disease with a cardiac bypass. He had two routine visits and had no complaint of chest pain.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for extracranial carotid artery stenting (CAS). Per the available records, this patient is a high surgical risk to undergo CEA because he has bilateral carotid stenosis with left- and right-sided occlusion. This supports that the patient is at high-risk to undergo CEA. Moreover, there are adequate data supporting a role for CAS in this patient’s clinical setting. Overall, CAS is a reasonable alternative to CEA in select patients with high-grade asymptomatic stenosis or symptomatic carotid stenosis.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for endovascular stenting.Nutcracker syndrome is a condition that is relatively rare, with few providers having significant hands-on experience. Medical literature on the subject of nutcracker syndrome is mainly based on case reports and small case series. Due to this limited experience, there are no established guidelines regarding this condition. There are, however, generally accepted indications and treatment options. Generally accepted indications for treatment include flank pain, particularly on the left side, hematuria either gross or microscopic (not absolutely required), evidence of renal vein compression by imaging studies including CT scan, and evidence of vascular engorgement.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a coronary angiogram with stent placement. Per the medical records, the patient has coronary artery disease without evidence of flow limitation by symptoms or by stress echocardiogram. While computed tomography fractional flow reserve (CT-FFR) results were noted as abnormal, this method of measuring FFR is not well studied. In this case, there is either no ischemia due to lack of flow limitation or stable silent ischemia in the mid-left anterior descending (LAD) territory with a false negative stress test. In either of these scenarios, revascularization with coronary stenting has not been shown to improve outcome compared to standard medical therapy alone and is not recommended according to the current guidelines.

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 Stentwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.