Diagnosis: Immunologic disorders/Arthritis.
Treatment: Radiology Services.
The insurer denied the Radiology Services. The denial was overturned.

The patient with a past medical history (PMH) of obesity and psoriatic arthritis (on Cosentyx and Arava). From a note the recent laboratory evaluation was notable for an erythrocyte sedimentation rate (ESR) of 94, despite well controlled psoriatic arthritis (PsA). The subject under review is the medical necessity of the CT scan of the chest. The health plan's determination is overturned in whole.

The requested health service/treatment of CT scan of the chest is medically necessary for this patient. As stated, the patient has an ESR in the 90's without any explanation. As part of the work-up for a persistently elevated ESR, occult malignancy needs to be ruled out. Other causes for a high ESR include, but are not limited to, rheumatologic disease, such as PsA; however per chart review, her PsA is well controlled at this time on Cosentyx and Arava.

Infection is another cause of an elevated ESR; however, this seems very unlikely given the 2 years history of an elevated ESR, lack of fevers and normal white blood cell count (WBC) (recent labs revealed a WBC of 8.3 and an ESR of 94). It is reasonable and consistent with the standards of care to check a CT of the chest without contrast to rule out an occult malignancy.