Diagnosis: Abdominal pain
Treatment: Computed tomography (CT) scan (procedure code 74177)
The insurer denied coverage for the CT scan (procedure code 74177).
The denial is upheld.

The patient was complaining of bloating, left sided abdominal discomfort which was mostly epigastric, arm pain, shortness of breath (SOB), and coughing. Her vital signs were stable and the oxygen saturation was 99 percent (%) on room air. Her physician ordered a computed tomography (CT) scan of the chest, abdomen, and pelvis. There was a family history of metastatic breast cancer and pancreatitis. The CT scan was read as having no specific findings to account for the patient's symptoms.

Milliman Care Guidelines (MCG) guideline A-0013 lists clinical indications for an abdominal/pelvic CT scan. These indications include having an aortic aneurysm, abdominal abscess, evaluation of a known cancer, jaundice, evaluation of severe liver disease, abdominal mass, and abdominal pain if there are other indications. These indications include having unexplained pain after a plain X-ray or ultrasound imaging, intestinal obstruction, suspected diverticulitis, suspected splenic infarction, suspected appendicitis, and persistent right upper quadrant (RUQ) pain after obtaining an ultrasound. The patient did not have these conditions. She also did not have acute pancreatitis, complicated pyelonephritis, or abdominal trauma.

This patient had some abdominal discomfort and bloating. She did not have a known cancer or abdominal mass. MCG guidelines advise obtaining ultrasound imaging for unexplained abdominal pain prior to obtaining a CT scan. Since there is no prior ultrasound, mass, or known malignancy, the abdominal and pelvic CT scan did not meet MCG guidelines.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The medical necessity for CT scan (procedure code 74177) is not substantiated.