Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peripheral Artery Disease
Treatment: Surgery to restore blood circulation for blockage
The insurer denied coverage for surgery to restore blood circulation for blockage.
The denial is overturned.

This case involves a patient with a history of peripheral artery disease and diabetes.  

A vascular ultrasound with pulse volume recordings was obtained on the patient.  The ankle-brachial indices, pulse volume recordings, and segmental limb pressures were obtained at rest.  The findings were suggestive of moderate to severe peripheral vascular disease within the right lower extremity.  Inflow and femoral-popliteal disease were suspected.  The right ankle-brachial index was 0.48 and the toe systolic pressure was 0.40.  There were findings suggestive of mild peripheral vascular disease with the left lower extremity.  Femoral-popliteal disease was suspected in the left lower extremity.  The left ankle-brachial index was 0.83 and the toe brachial index was 0.39.

The patient presented to the vascular surgeon's office with complaints of rest pain secondary to extremity atherosclerosis and carotid artery stenosis.  The pulse volume recording (PVR) studies were consistent with inflow and outflow occlusive disease.  The provider recommended angiography with possible intervention.  

The patient had an abdominal aortogram and bilateral lower extremity angiogram with nonselective catheter placement.  The findings showed a critical right common iliac stenosis beyond its origin, 99% (percent) stenosis, with patent external iliac artery and common femoral profunda femoris arteries.  The superficial femoral artery was occluded from its origin and reconstituted the distal superficial femoral artery and popliteal artery that led down to three-vessel runoff to the mid-calf.  There was severe stenosis greater than 80% of the proximal external iliac artery with patency beyond this.  The common femoral and profunda femoris artery were patent.  The femoral artery was somewhat diminutive, but patent to the distal thigh where it became moderately stenosed which was more severe in the above-knee popliteal artery.  The anterior tibial artery was occluded from its origin.  The posterior tibial artery was patent, but had markedly decreased flow to the foot consistent with severe occlusive disease at the level of the ankle and beyond.  The peroneal artery was visualized approximately, but then there was no flow beyond its mid segment.  There was a plan for right common iliac artery stenosis with stent with retrograde access to the popliteal for treatment of the superficial femoral artery occlusion.  The left-sided access would be necessary to treat the superficial femoral artery occlusive disease and tibial disease.

In an appeal letter, it was stated that the patient had critical limb ischemia as demonstrated by bilateral lower extremity rest pain, absent pedal pulses, diminished femoral pulses, and ankle-brachial index on the right of 0.48.  She has been utilizing aspirin and atorvastatin for many years.  She quit smoking.  The diagnostic angiogram was reviewed in detail.  There was a plan for right common iliac artery stenosis with stent with retrograde access to the popliteal for treatment of the superficial femoral artery occlusion.  The left-sided access would be necessary to treat the superficial femoral artery occlusive disease and tibial disease.

The health plan did not act reasonably, and the denial of the right leg endovascular revascularization is not in the best interests of the patient.  This patient requires right leg revascularization and is at high risk for limb loss.

The right leg endovascular intervention is medically necessary for avoiding limb loss.

Per the referenced literature, endovascular therapy has evolved to the point that among experienced operators, an endovascular first strategy is reasonable for the treatment of most patients with intermittent claudication or critical limb ischemia.  The patient was sent for a referral for rest pain.  The patient reported rest pain, claudication, and severe limitation of lifestyle.  She had quit smoking previously.  Extensive workup was initiated with non-invasive imaging.  The patient's ankle brachial index on the right was critically low and the pulse volume recording testing indicated severe diminution of the inflow and outflow of the right lower leg.  Based on her symptoms and imaging results, she was taken for a diagnostic angiogram which revealed multi-level critical limb ischemia with severe aorto-iliac stenoses, femoral-popliteal disease, and tibioperoneal disease.  Based on the imaging and clinical findings, the right leg revascularization is medically necessary.  Therefore, the denial of coverage for leg surgery to restore blood circulation for blockage was inappropriate and is overturned.  

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The insurer's denial of coverage for leg surgery to restore blood circulation for blockage is overturned. Medical necessity is substantiated.