Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Peripheral Artery Disease

Treatment: Vascular surgery (37220, 37221, 37224, 37226, 37228) x 1

The insurer denied coverage for vascular surgery (37220, 37221, 37224, 37226, 37228) x 1

The denial is upheld. 

This is a patient requesting a review for endovascular surgery (37220, 37221, 37224, 37226, 37228).

Records state the patient has a history of an aortic angioplasty and is complaining of their legs bothering them. The records state that the patient has narrowing. No further history is provided. No details of symptoms, nature of discomfort or location of discomfort, inciting or relieving factors, functional impact on occupation or other activities, appropriate efforts to control symptoms without invasive procedures, or the outcome of such efforts. No physical exam of the vascular system is provided, and no physical exam of limbs with regard to ulcers or skin wounds is provided. Noninvasive studies documented report normal left ankle brachial index and minimally decreased right ankle brachial index. Ultrasound exam indicated recurrent stenosis in the distal aorta with flow rate 431 centimeters (cm)/second (sec). Mild stenosis was noted in each iliac artery. 

The physician recommended angiography and intervention.

No procedure qualifies as medically necessary in the absence of a reasonable history and physical exam, neither of which are provided. Missing information include documentation of details of history supporting the diagnosis of a condition such as claudication and ulcers. The severity of symptoms dictates appropriate care, and this includes the presence or absence of meaningful legitimate functional impairment. Presence or absence of associated physical findings (presence or absence of healthy pulses, presence or absence of ulcers or wounds on the lower extremities) is important to document in support of the diagnosis of symptomatic arterial disease. Noninvasive tests such as ankle brachial index and pulse volume recording are used to correlate severity of disease with symptoms. In this case ankle brachial index is essentially normal, and provocative testing (exercise with treadmill) has not been performed. Pulse volume recording is not provided. 

In the hypothetical event that a patient has reasonably documented symptoms such as claudication (not established in this case) many or most patients can be managed without invasive procedures through exercise programs, pharmacologic care such as cilostazol, and current evidence based peer reviewed expert consensus guidelines published by the Society for Vascular Surgery recommend a trial of such measures for most patients with claudication. In this case there is no documented effort to manage symptoms without intervention. 

The procedures requested (37220, 37221, 37224, 37226, 37228) cover treatment of disease in the iliac, femoral, popliteal and tibial segments of the arterial tree, but this patient's arterial disease (which may or may not be severe enough to warrant treatment) is located primarily in the aorta. The requested procedures would be inappropriate for treatment of the patient regardless of the concerns raised in sections above. For each of these reasons individually and collectively, the recommended procedures do not qualify as medically necessary based on the information provided. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for vascular surgery (37220, 37221, 37224, 37226, 37228) x 1 is not substantiated.