Diagnosis: Chronic chest pain and pressure

Treatment: CPT- 71270 Computed Tomography (CT) of the chest without and with contrast (dye)

The insurer denied coverage for CPT- 71270 Computed Tomography (CT) of the chest without and with contrast (dye).

The denial is upheld.

This is a female patient who has been complaining of mid-sternal chest pain and pressure which has been chronic. The patient underwent a left heart catheterization which was unremarkable. The patient still complains of chest pain and pressure. She has a medical history of hyperlipidemia and diabetes mellitus. For further evaluation, a computed tomography (CT) scan of the chest with and without contrast was recommended to evaluate for pathology in the pulmonary and other vascular beds.

A report was written by the patient's cardiologist describing the patient's sestamibi myocardial single-photon emission computed tomography (SPECT) imaging scan. The findings state that the patient's left ventricle (LV) was normal in size, and there is a small in size, moderate in severity predominately fixed apical wall perfusion defect seen. With gated SPECT, the global LV function was normal. The patient's left ventricular ejection fraction (LVEF) was calculated at 87%; regional wall motion/thickening was normal. The impression stated that this was an abnormal myocardial SPECT imaging scan. They could not rule out a small in size, area of apical ischemia. Exercise was excellent. The patient had no symptoms. The patient's stress electrocardiogram (EKG) was equivocal. The hemodynamic response was normal. The patient's resting LV function was normal.

There is no basis to perform a CT scan with and without contrast for possible pathology in the chest. Compared with conventional angiography, the angiograms produced by multi-detector CT scanners are much lower in quality and are suboptimal for diagnostic purposes. In a patient who has already undergone selective coronary arteriography, CT has no role in the diagnosis of any cardiac disease. In fact, the sequence is in reverse where coronary angiography would be the next step if the CT was inconclusive with regard to the heart.

As for a search for other causes of chest pain including a pulmonary etiology, Up to Date with regard to the use of imaging notes "Indications for chest radiograph include suspected pulmonary causes of chest pain, heart failure or rib fracture." There is no mention of the use of chest CT with or without contrast. This patient has had a negative electromagnetic radiation (x-ray) imaging of the chest. CT is reserved for situations where a specific disease entity is being considered. The patient's cardiologist does not provide a differential diagnosis that a CT of the chest would help to clarify. In such situations, is not considered clinically useful.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for CPT- 71270 Computed Tomography (CT) of the chest without and with contrast (dye) is not substantiated. The insurer's denial should be upheld.