Conversations in Cardiology: Will Insurance Cover Cath in Asymptomatic Patients?

Morton Kern, MD, often engages his colleagues via email in brief, informal dialogue on clinically relevant topics in cardiology.

Conversations in Cardiology: Will Insurance Cover Cath in Asymptomatic Patients?

Morton KernMorton Kern, MD, of VA Long Beach Healthcare System and University of California, Irvine, often engages his colleagues via email in brief, informal dialogue on clinically relevant topics in interventional cardiology. With permission from the participants, TCTMD presents their conversations for the benefit of the cardiology community. Your feedback is welcome—feel free to comment at the bottom of the page.


Paul Teirstein, MD (Scripps Clinic, La Jolla, CA), asks:

Just got off the phone doing a peer-to-peer with United. Patient of Dr. Smith stented in 2014. Stress test showed very clear > 2-mm horizontal depression ant/lat. No symptoms at home or with peak exercise. Nice conversation with “peer” cardiologist, who told me as of January 1, 2021, there are no approvals for cath unless patients have symptoms. Obviously, this is based on ISCHEMIA trial. Lots of issues here. ISCHEMIA showed increase in nonprocedural MI in patients medically managed so I don’t see the evidence supporting United’s position to not approve catheterization unless symptoms are present. Does this mean we can’t do a heart cath if a patient has a new decrease in EF? What about new ventricular tachycardia? Also, the peer reviewer said they would approve CT angiography (CTA) to rule out left main disease, but not an invasive cath. Of course, CTA won’t be helpful for in-stent restenosis (yet). OMG!

I called the patient and went over his history and symptoms. I told him to call Dr. Smith if he gets symptoms. This 68-year-old is moving to Medicare (no prior approvals needed) on July 1, so I told him he could likely wait until then but also that he should get an angiogram.

Just sharing a new wrinkle to be aware of.

Kern replies:

I understand the frustration. The scenario is probably not rare, but as the VA system doesn't have denials for us it's a moot point. However, if I look at the events it strikes me that 1) The stress test for an asymptomatic man was questionable unless surgery is planned, and even then, may not be needed. 2) Once you have the ischemic test without symptoms, is medical therapy enough (ie, ISCHEMIA trial path) or are you sitting on a critical in-stent restenosis or new left main? 3) CTA is problematic for stented lesions, as you note. I also think CTA should have FFR with it if there are concerning lesions. 4) Lastly, the insurance-reviewer physician sounds like he is practicing medicine without seeing the patient or accepting responsibility for his recommendations.

Colleagues, wassup?

Bonnie Weiner, MD, replies:

So, here is the language from the diagnostic appropriate use criteria (AUC). “The indications developed in Section A relate to appropriateness of coronary angiography. A decision about the performance of left heart catheterization and left ventriculography is left to the discretion of the operator and the patient’s primary physician.”

Specific to post-PCI patients:

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Although I, too, would like to know what prompted the stress test, as Mort points out it by itself may not have been indicated. Once you have the information, however, the game changes. Do you have the risk score for the stress test?

The key is at its core the language in my initial paragraph. The appropriateness of the procedure is based on the physician’s discretion.

Jeffrey Moses, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), replies:

Well. They keep moving the goalposts. The canard was that stenting didn’t prevent MI. We know now that spontaneous MI is reduced in FAME, ISCHEMIA, and COMPLETE, etc. Certainly, raising the idea of preventive stenting to at least a reasonable consideration. But apparently the only thing that matters now is mortality. This has nothing to do with patient care. Plus, this could be in-stent restenosis, which was excluded from these trials.

Kirk Garratt, MD, MSc (ChristianaCare, Newark, DE), replies:

Very troubling. It’s one thing to lean on best practice guidelines that are definitive, but as you point out, Jeff, the debate over stents preventing spontaneous MIs is far from settled. I guess the United docs weren’t impressed with Chaitman’s Circulation paper in February that took a hard look at MIs and their relationship with CV mortality in ISCHEMIA: “Conclusions: In ISCHEMIA, type 1 MI events using the primary and secondary definitions during 5-year follow-up were more frequent with an initial conservative strategy and associated with subsequent cardiovascular death.”

ISCHEMIA in no way justifies withholding invasive assessment of someone with asymptomatic ischemia, especially if they have known disease. At least they approved a CTA. Can you get CT-FFR at your place, Paul?

Steven R. Bailey, MD (LSU Health, Shreveport, LA), replies:

I just spoke to a UnitedHealthcare cardiology nurse specialist. The currently accessible criteria are from January 1, 2021. Their clinical guidelines site is at:

The United criteria for Cardiology & Radiology can be found here, starting on page 252. Interestingly, United does not recognize improvement in symptoms or decreased clinical events. Anything not covered in this list does require peer-to-peer. Seems that silent ischemia in diabetics/women and other groups is not addressed.

In Texas, carriers are liable for their approval process. I regularly would document the conversation including the MD peer reviewer’s name. I must say I had a near 100% approval when that was part of the information requested during the peer-to-peer discussion. It’s an opportunity for systems/organizations to engage with United regarding patient-related outcomes.

Weiner replies:

As others have also pointed out, this does not address prior revascularization.

Lloyd Klein, MD (University of California, San Francisco), replies:

Of course, I have been a critic of the AUC process for precisely this sort of coverage issue for a long time, even wrote a warning about it in 2016 that asked SCAI to take a position on the subject.

We wrote: "When decisions for coverage of medical care are based strictly on categories or algorithms, opportunities for physician-patient interaction that lead to shared decision‐making and patient‐centered care are limited. In particular, the weight of patient preference would be at the discretion of payors. Exclusions based on inflexible adherence to AUC that were never intended to be rigid categorizations may harm patients.

It is now happening, as insurance companies have been encouraged to do whatever it is they want to do. We as a profession have been too silent, so there have been and continue to be consequences.

Garratt replies:

Your point about advocacy is a great one. SCAI and other agencies are aware of this risk and have tried to get (and keep) the ear of relevant political folks. It’s an expensive business, even during pandemics. How many on this list have contributed to the SCAI PAC?

J. Jeffrey Marshall, MD (Northside Hospital, Atlanta, GA), replies:

I agree with Steve, using the peer-to-peer “physician’s” name is the best method to get 100% approval. Language about the risk of MI and death as possible complications for not performing angiography is also helpful.

Teirstein replies:

Thanks for all the feedback. Coincidently, I happened to speak to the same reviewer again today. I did get her name (very good advice), and she was very nice but explained she was just following guidelines. She said the guidelines for commercial insurers can be found at (although I found the website complicated to navigate), and she claimed the same guidelines are followed by all commercial insurers in the US with some exceptions in New Mexico and Texas. Today I was looking for approval for a stress test on a new asymptomatic patient establishing care with me who had bypass surgery 10 years ago. The reviewer denied the stress test, explaining the guidance states I can get one imaging stress test 1-2 years after a stent or one stress test 5 years after a bypass but no other stress tests unless the patient is symptomatic. She also told me for asymptomatic patients they allow screening treadmills but no imaging. Interesting. I suppose I am showing my age, but it seems to me a stress test every few years on a patient with stents or bypass isn’t such a bad idea. I guess I am wrong.

BTW, I find the peer-to-peer reviewers can often be influenced by politics, ie, my attitude, my degree of friendliness, etc. Often the reviewers thank me for starting the National Board of Physicians and Surgeons (they are usually retired physicians who can’t stand MOC). Sometimes I hang up the phone and say: “I just got this patient a stent because the reviewer liked me.” So much of this is absurd.

Stephen Ramee, MD (Ochsner Medical Center, New Orleans, LA), replies:

In the 1990s, our own insurance company, an HMO that the doctors owned, used to require preauthorization prior to all outpatient angiograms. That is, until I showed them that for over 3,000 cases requiring preauthorization, none were denied. We both agreed it was a waste of time and money.

I'm enjoying the banter now, and I agree with Lloyd that we saw this coming when we cardiologists got on board by developing the AUC and we knew the insurers would make these laws, not guidelines.

Garratt replies:

Steve, your experience 25+ years ago shows what vertical alignment can do to get past these problems. The same can work today, but since our payment models have changed a lot, there’s potential to go even further with an integrated model. By an incredible coincidence, my healthcare organization announced yesterday a 10-year collaboration agreement with Highmark, a large insurer in the mid-Atlantic. Each company remains intact and independent, but a new joint venture has been formed that will share risk and reward. The low-hanging fruit will be eliminating wasteful exercises like preauthorization that isn’t needed anymore when both the insurer and care provider have aligned interests. Beyond that, though, this agreement has the potential to drive the kind of change we really need in a value-based healthcare economy. We’ll be able to steer more resources toward disease prevention (population health) because we’ll be in a position to sustain profitability through the transition. It’s a pretty cool approach.

Samuel Butman, MD (Heart & Vascular Center of Northern Arizona, Cottonwood), replies:

“So much of this is absurd.”

There is no question that obtaining insurance approvals is more than a just a pain. They are a frustrating, time-consuming process that often insults our intelligence. So, let’s be real, the approval process is a game, an evil and nefarious game, which is unique to this country. This “decision-making” step has become a strategic business plan in how intermediaries can make a profit with no direct patient-care responsibilities.

Why have insurance companies continued to beef up their processes for approvals? Do we do “too many” tests and procedures in this country? Maybe yes. Do we have better outcomes? Not sure. But I do know that we pay more for everything when it comes to medicines, procedures, materials, etc. 

Back to the matter at hand. As stated by the group, much wiser than I, the real question is whether a stress test ordered for an asymptomatic “noncardiac” patient was appropriate unless surgery was planned. And even then, why was it deemed necessary? I do not order them very often in asymptomatic patients before or after any intervention, nor do I use some of the other suggested noninvasive diagnostic modalities. In the last few years, however, I have converted from being a “nonfan” of using CT calcium scoring to more of a “fan,” simply to help improve patient compliance and achieve a better understanding of its real or potential coronary disease prognosis. There I go, digressing again . . .

The arguments regarding CTA, in-stent restenosis, possible left main disease, and so forth are all important but not necessarily cogent to this case. If the test was sufficiently ischemic to the point of marked ST-segment depression with a drop in blood pressure or worse, then I agree that a radial-approach heart catheterization is low risk and more often a win-win, if not simply to find normal vessels!

All my interactions during peer-to-peer chats have been brief and easy despite the time on hold. Perhaps I am luckier than most. A novel option might be to include a picture of a recent left main stenosis or multivessel disease in the request for approval in an asymptomatic patient with an abnormal stress test. We all should get the name of the insurance “peer” and maybe the “peer” manager, as well, so that the patient can write them a note, too, if need be. Let’s hope that a sad follow-up note will never need to be written by a patient’s family to those “peers” though.

Jonathan Tobis, MD (UCLA Health, Los Angeles, CA), replies:

What if we had "Medicare for All" and eliminated the private insurers completely?

Garratt replies:

The nuclear option—that would eliminate preauths, but I don’t think you’d be happier.

I like letting market forces work, just not letting them run amok. Fostering alliances and collaborations is way better than handing the reins to big government IMHO.