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

The patient is a female with obesity and well controlled psoriatic arthritis. The patient has had a very elevated erythrocyte sedimentation rate (ESR) for 2 years. Recently the patient's ESR was 94. The patient's psoriatic arthritis (PsA) is well controlled on Cosentyx and Arava.

The issue in this case under review is the medical necessity of a computed tomography (CT) of the abdomen/pelvis (A/P) without contrast to rule out occult malignancy. The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of CT scan of the abdomen is medically necessary for this patient. The patient has an elevated ESR without explanation x 2 years. Her PsA is well controlled at this time on Cosentyx and Arava, so this would not explain the elevated ESR. Other causes for an elevated ESR include, but are not limited to, malignancy and infection. The provider has recommended a CT A/P to rule out occult malignancy and has also ordered a CT chest, as well as recommended age appropriate malignancy screening with mammogram, pap smear and colonoscopy. This is consistent with the standard of care and a reasonable next step in further working up the elevated ESR. The patient did have an abdominal ultrasound (U/S) that showed hernia, so a CT A/P would be the next step, as the U/S was unrevealing other than a hernia. Infection seems less likely given the persistently elevated ESR x 2 years, lack of fevers/chills/night sweats and the normal white blood cell count (WBC) (from the late 2019 labs).