As a result of the recent pre-authorization denials of critical cardiac imaging procedures by Delaware insurance companies, state legislators will meet with Delaware Insurance Commissioner Karen Weldin Stewart on April 13.

The meeting comes after hundreds of patients have been denied coverage for cardiology stress tests over the last few months, according to The News Journal.

"The biggest [problem] is that people making the decisions in Delaware are not physicians," Amy Murphy, spokeswoman for the American College of Cardiology, told DOTmed News. "They're not using our or any physician-produced or developed criteria."
Stewart's office is planning an investigation of three insurance companies that have denied patients coverage for these tests, including Aetna, Blue Cross Blue Shield Delaware and Coventry Health Care. Last month, Stewart told The News Journal that she could not investigate based on just one denial complaint; patients and physicians have to bring forward this information.

Since then, more reports surfaced in The News Journal about patients being denied coverage. One man, Michael Fields, nearly died because he was denied coverage three times for a stress test before he was sent in for a quadruple bypass surgery that prevented a massive heart attack. A stress test would have shown severe arterial blockage.

"Companies who do not use physician-based criteria and have no medical education are [deciding] whether or not a patient gets a test," Murphy says. "We don't know what they're basing it on."

Blue Cross Blue Shield of Delaware did not return calls for comment, but in a News Journal article, representatives said all claims decisions are based on "internal guidelines modeled after national guidelines from organizations such as the American College of Cardiology."

Patient Protection a Factor

MedSolutions, a third-party company that reviews prior approval requests, including Aetna's, has said it wants to cut down on inappropriate testing, which could expose patients to radiation unnecessarily.

MedSolutions has a process it goes through when considering pre-authorization requests, and sometimes denials are based on the fact that a patient has other testing options to consider, says a source close to the company.

A denial "doesn't mean a patient wouldn't ultimately get that test, but we don't necessarily take every patient that walks into the office and give them that test," the source says. "Part of what we do as part of the pre-authorization process is to make sure that when a patient is talking about taking a test, he knows what all the risks are, what other tests are available, and getting the best test for him at that time."

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