Clinical co-sign
CASE-008
Declined — no basis to appeal · Appeal deadline: 20 January 2027 82 days remaining
You are being asked one question: is the clinical argument below accurate? A billing clerk confirms separately that the citations and quotations hold up, which is a different question and not one you have to re-check here.
What the payer refused, and why
- Patient
- Creola Heller
- Payer
- NORTHBECK HEALTH PLAN
- Service denied
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- Magnetic resonance imaging, cardiac, with contrast material, including stress imaging and morphology CPT/HCPCS 75561 · ICD-10 R06.00
- Payer's stated reason
The original determination is UPHELD. Coverage for the service listed above remains DENIED. ... The reviewer concurs with the original determination that the submitted records do not establish that a contraindication to magnetic resonance imaging has been addressed: the record identifies a permanent pacemaker without stating whether the device is MRI-conditional, and the appeal submission did not supply this information. On that basis the reviewer upholds the denial of cardiac magnetic resonance imaging and did not reach the remaining criteria under NBH-CARD-014-3.
The clinical argument, criterion by criterion
The patient is an 83-year-old woman presenting with progressive exertional dyspnoea. An initial evaluation including a 12-lead ECG and a transthoracic echocardiogram was completed in March 2026. The echocardiogram was technically limited and inadequate to resolve the clinical question of septal thickening, leaving a differential between infiltrative cardiomyopathy and ischemic heart disease. The cardiac MRI is requested to distinguish these conditions and guide specific management steps. However, the patient has a permanent pacemaker, and the records show that its MRI compatibility remains unconfirmed and outstanding.
| Criterion | Verdict | Chart evidence |
|---|---|---|
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NBH-CARD-014-3.1 The member has symptoms consistent with cardiac disease, including but not limited to chest pain, dyspnoea on exertion, syncope, or palpitations, that have persisted for at least six weeks, or that are documented as progressive. |
Satisfied
The patient has progressive exertional dyspnoea (shortness of breath on exertion) that has persisted for more than six weeks and is documented as progressive. |
Eighty-three year old woman reporting six weeks of increasing breathlessness on exertion. enc/2026-02-18/internal-medicine Her symptoms have progressed further since February; she now stops three times on the same walk and has developed mild orthopnoea. enc/2026-04-22/cardiology |
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NBH-CARD-014-3.2 An initial diagnostic evaluation has been completed and documented. This evaluation must include a twelve-lead electrocardiogram and a transthoracic echocardiogram performed within the twelve months preceding the request. |
Satisfied
A 12-lead electrocardiogram and transthoracic echocardiogram were both completed in March 2026, within the 12 months preceding the June 2026 request. |
Twelve-lead electrocardiogram performed 2 March 2026. enc/2026-03-02/ecg Transthoracic echocardiogram performed 9 March 2026. enc/2026-03-09/echocardiogram |
|
NBH-CARD-014-3.3 The results of the initial evaluation under section 3.2 are inconclusive, equivocal, or technically inadequate for the clinical question posed, and the treating clinician has documented what remains unresolved. |
Satisfied
The echocardiogram is documented as technically inadequate due to poor acoustic windows, and the clinician outlines that the differential between an infiltrative process (amyloidosis) and ischaemic heart disease remains unresolved. |
The echocardiogram is technically inadequate for the clinical question. Her symptoms have progressed further since February; she now stops three times on the same walk and has developed mild orthopnoea. NT-proBNP 1840 and a mildly raised high-sensitivity troponin support a cardiac cause. The differential is between an infiltrative cardiomyopathy, most importantly cardiac amyloidosis given her age and the septal appearance, and ischaemic disease that the paced rhythm prevents me from excluding electrocardiographically. enc/2026-04-22/cardiology |
|
NBH-CARD-014-3.4 The requested study is expected to change clinical management, and the treating clinician has documented the specific management decision that depends on the result. |
Satisfied
The cardiologist documents that the cardiac MRI results will directly guide management: a positive amyloid pattern will lead to disease-modifying therapy after confirmatory tests, whereas an ischaemic pattern will lead to invasive angiography. |
Cardiac magnetic resonance with late gadolinium enhancement and T1 mapping is the study that distinguishes these, and the distinction determines management directly: a positive amyloid pattern would take her to bone scintigraphy and serum free light chains and, if confirmed, to disease-modifying therapy, whereas an ischaemic pattern of enhancement would take her to invasive angiography. enc/2026-04-22/cardiology |
|
NBH-CARD-014-3.5 There is no contraindication to magnetic resonance imaging, or, where a relative contraindication exists, the medical record documents that it has been addressed. |
Not satisfied
The patient has a permanent dual-chamber pacemaker in situ, which is a relative contraindication. The medical record explicitly states that this conditionality has not yet been addressed and remains outstanding. |
Did not address the pacemaker's MRI conditionality in this letter; that detail was not obtained before the appeal was filed and remains outstanding. enc/2026-06-25/cardiology-appeal-letter |
|
NBH-CARD-014-4.1 The member presents with stable chest pain and an intermediate pre-test probability of coronary artery disease, as documented by a validated risk assessment tool. |
Not satisfied
The patient presents with progressive exertional dyspnoea and is explicitly documented to have no chest pain, meaning she does not present with stable chest pain. |
No orthopnoea, no chest pain, no syncope. enc/2026-02-18/internal-medicine |
|
NBH-CARD-014-4.2 The member has not undergone coronary revascularisation, and no coronary stent is in place, unless the requested study is for the evaluation of graft patency. |
Not satisfied
The patient's problem list notes a history of coronary artery bypass grafting, which is a coronary revascularisation procedure. |
No chart evidence cited |
|
NBH-CARD-014-4.3 The member's heart rate is expected to be controllable to a rate suitable for the acquisition, or the imaging facility has documented capability for high-heart-rate acquisition. |
Insufficient documentation
The record is silent regarding the controllability of the patient's heart rate or the imaging facility's high-heart-rate acquisition capabilities. |
No chart evidence cited |
|
NBH-CARD-014-6.1 Advanced cardiac imaging performed solely for screening in an asymptomatic member, absent a documented high-risk inherited cardiomyopathy in a first-degree relative. |
Not satisfied
The patient is symptomatic, with progressive exertional dyspnea and orthopnea, meaning the imaging is not being performed solely for screening in an asymptomatic member. |
Her symptoms have progressed further since February; she now stops three times on the same walk and has developed mild orthopnoea. enc/2026-04-22/cardiology |
|
NBH-CARD-014-6.2 Repeat advanced cardiac imaging of the same anatomical territory within twelve months of a prior diagnostic-quality study, absent a documented interval change in clinical status. |
Not satisfied
The patient has not undergone a prior diagnostic-quality advanced cardiac imaging study of the same territory within the past twelve months. Her prior transthoracic echocardiogram was technically inadequate and of poor image quality. |
Transthoracic echocardiogram performed 9 March 2026. Image quality is poor secondary to body habitus and limited acoustic windows; the apex and the lateral wall are not adequately visualised. enc/2026-03-09/echocardiogram The echocardiogram is technically inadequate for the clinical question. enc/2026-04-22/cardiology |
|
NBH-CARD-014-6.3 Advanced cardiac imaging performed for research purposes or as part of a clinical trial protocol funded by the trial sponsor. |
Not satisfied
The requested cardiac magnetic resonance imaging is for active clinical diagnostic purposes and to directly guide medical management, rather than for research purposes or clinical trial protocols. |
The differential is between an infiltrative cardiomyopathy, most importantly cardiac amyloidosis given her age and the septal appearance, and ischaemic disease that the paced rhythm prevents me from excluding electrocardiographically. Cardiac magnetic resonance with late gadolinium enhancement and T1 mapping is the study that distinguishes these, and the distinction determines management directly enc/2026-04-22/cardiology |
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