The patient has morbid obesity, hypothyroidism and hypertension. The patient presented with symptoms of exertional dyspnea and fatigue with mild to moderate exertion for 6 months. Patient had palpitations and dizziness. An electrocardiogram (EKG) showed sinus rhythm with a rate of 84 beats per minute and poor R wave progression anteriorly. There were nonspecific ST and T changes.

A stress (persantine) nuclear study was performed, showing a perfusion defect in the anterior and apical segments with stress, equivocally improved at rest. Images were suboptimal due to artifact related to the patient's size, with a body mass index (BMI) of 30. Post stress test ejection fraction (EF) was 68% by gated Single-photon emission computed tomography (SPECT). A positron emission tomography (PET) scan was ordered by the patient's provider. it is medically necessary to rule out myocardial ischemia in this patient with symptoms which may represent myocardial ischemia who has had an equivocal stress nuclear study. The reason for the equivocal stress nuclear study is likely the patient's large size, which results in degradation of the image. This is less likely to happen with a PET scan.

Cardiac PET myocardial perfusion imaging has higher diagnostic accuracy and lower radiation dose exposure during a shorter examination time compared with stress nuclear imaging, and is an established, highly accurate test for the detection of coronary artery disease. In the study by Danad et al (reference 3 below) cardiac PET stress imaging had a better diagnostic accuracy than either SPECT (stress nuclear) or CT coronary angiography.

In further support, Per Milliman Guidelines, one indication for cardiac PET is for patients needing an assessment of myocardial viability in whom SPECT myocardial perfusion scan or stress echocardiogram findings are inconclusive. That is the clinical situation for this patient.

The health plan's determination of medical necessity is overturned in whole