Diagnosis: Coronary Artery Disease
Treatment: Positron Emission Tomography (PET SCAN) (78492), Pre-service
The insurer denied the Positron Emission Tomography (PET SCAN) (78492), Pre-service.
The denial is overturned.

The patient is a female with cardiac risk factors of hypertension, DM (diabetes mellitus) type II, dyslipidemia, overweight, family history of CVD (cardiovascular disease), and a sedentary lifestyle. The patient has chest discomfort, SOB (shortness of breath), MI (myocardial infarction) with occluded RPDA (right posterior descending coronary artery), CAD (coronary artery disease) with stents of the LAD (left anterior descending) and LCx (left circumflex coronary artery), edema, TIA (transient ischemic attack), PAD (peripheral arterial disease).

The patient has new chest pain with an abnormal EKG (electrocardiogram) positive for reproducible ischemia. A cardiac SPECT (single photon emission computed tomography) stress test demonstrated a moderate to severe inferior wall defect with equivocal redistribution and moderate inferior wall hyperkinesis, and a cardiac PET (positron emission tomography) scan was recommended.

Yes, the requested positron emission tomography scan is medically necessary.

The patient has new chest pain with an abnormal EKG (electrocardiogram) positive for reproducible ischemia. A cardiac SPECT (single photon emission computed tomography) stress test demonstrated a moderate to severe inferior wall defect with equivocal redistribution and moderate inferior wall hyperkinesis. In the setting of an equivocal cardiac SPECT (single photon emission computed tomography) study, an old inferior wall MI (myocardial infarction), and new symptoms, a cardiac PET (positron emission tomography) scan is the next examination to evaluate for peri-infarct ischemia. This would determine the treatment options and is standard of care.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.