Issued and entered December 21, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On August 6, 2002, the Petitioners, XXXXXXXXXXXXXXXX filed a request for external review with the Commissioner of Financial and Insurance Services (“Commissioner”) under the Patient’s Right to Independent Review Act, MCL 550.1901, et seq. They filed the requests on two separate external review request forms but since the issues were essentially identical they were combined into one review. Resolving the issues required a medical opinion. Accordingly, the Commissioner assigned it to an independent review organization (“IRO”) which provided its recommendation to the Commissioner on August 29, 2002.

On June 23, 2001, Petitioners had CAT scans of the chest as well as CT scan bone density studies. BCBSM has failed to pay for these procedures.

III
ISSUE

Did Blue Cross and Blue Shield of Michigan (“BCBSM”) properly deny reimbursement for the procedures provided the Petitioners on June 23, 2001?

IV
ANALYSIS

Petitioner’s Argument

Petitioners have a family history of atherosclerotic vascular disease, cancer, and hypertension. Mrs.XXXXXXX had a stroke in July 1997 and liver failure in October 1997. She suffers from hypertension, fatigue, non-insulin dependent diabetes mellitus, menopause, allergies, hyperlipidemia, and hypothyroidism. Mr. XXXXXXX has a history of hypertension, insulin dependent diabetes mellitus, atherosclerotic vascular disease, allergies, G.E.R.D., and hyperlipidemia.

Mrs. XXXXXX also has a history of moderate plaque burden in her coronary arteries, mild to moderate left ventricular hypertrophy, diastolic dysfunction and mild mitral regurgitation. Mr. XXXXXX also, has a history of an extensive plaque burden in his coronary arteries, mild left ventricular hypertrophy with diastolic dysfunction, mild mitral regurgitation, cataract surgery and mild renal deficiency. Mrs. XXXXXX had some shortness of breath and chest pressure at the end of May 2001.

In June 2001, their physician, Dr. XXXXXXXX, recommended that the XXXXXXXX undergo heart scans to evaluate their present treatment protocols. The Petitioners believe that, because their physician felt the tests were medically necessary, the cost of the tests should be paid by BCBSM.

Respondent’s Argument

Petitioners are insured under BCBSM’s “Professional Services Group Benefit Certificate. The certificate includes coverage for CAT scans. However, if a CAT scan is performed for screening purposes or is not directly related and necessary to diagnosis it is not a covered benefit. In addition, the certificate expressly excludes experimental and investigational procedures. Experimental and investigational care is defined as a service, procedure, treatment, device or supply that has not been scientifically demonstrated to be safe and effective for treatment of the patient’s condition.

BCBSM’s medical consultants reviewed the Medical records of the Petitioners and concluded that, for Ms. XXXXXX, the CAT scan of the chest was of no value to the standard diagnostic regimen for coronary artery disease. For Mr. XXXXXXX, a CAT scan of the chest to screen for calcium scoring is investigational and inappropriate for someone with known coronary artery disease. It was also concluded that, for both Petitioners, the medical necessity of the CT scan bone density study was not established by the documentation.

For those reasons, BCBSM concluded that the procedures were used for screening purposes and therefore were not payable under their certificate.

IRO Recommendation

The IRO concluded that the CAT scan of the chest for diagnosis of coronary artery disease is not medically indicated for either Petitioner. Further, there was not enough information in the records of either Petitioner to support the necessity of the bone density studies. Coronary artery occlusive disease was already established by other means in both Petitioners so the CT scans and calcium scores did not add any new information.

Commissioner’s Review

It was the judgment of the IRO reviewer that the tests were not medically necessary. The reviewer had the benefit of reviewing the medical records in this matter. There is no basis upon which to conclude that the reviewer’s judgment was erroneous. The IRO’s recommendation, therefore, is adopted. Because the tests were not medically necessary they are not covered under the Certificate.

V
ORDER

The final adverse determinations of BCBSM dated July 29, 2002, are upheld. BCBSM is not required to reimburse for the CAT scans provided the Petitioners on June 23, 2001.

This is a final decision of an administrative agency. Under MCL 550.1915, MCL 600.631, MCR 7.101 and MCR 7.104, any person aggrieved by this order may seek judicial review no later than sixty days from the date of this order in the circuit court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.