Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Peripheral vascular disease (PVD). 
Treatment: Ambulatory surgery, blood vessel procedure. 

The insurer denied coverage for ambulatory surgery, blood vessel procedure. 

The denial is upheld. 

This is an adult patient who is being evaluated for treatment of possible aortoiliac arterial occlusive disease. The patient presented for a follow up for lower extremity pain. Reported having pain at rest and having a hard time walking around her house. Also reported significant fatigue walking up and down steps. The patient had previous iliac stenting many years ago. A computed tomography (CT) scan reportedly revealed significant plaque and stenosis in the common iliac arteries bilaterally. The patient also had stenosis of the abdominal aorta. While there are no palpable pulses bilaterally, clinical documentation for rest pain is not documented including no submitted ankle brachial index (ABIs). This patient continues to smoke and has history of chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD). The treating practitioner recommended an angiogram. The insurer has denied coverage for ambulatory surgery, blood vessel procedure, as not medically necessary. In a Final Adverse Determination letter, they stated that records do not show that the patient has tried and failed six months of other treatments. This must include medication, changing activity levels, and therapy exercises. The requested service is denied based on Turning Point guidelines named Peripheral Revascularization and Medical Record Documentation.

The rest pain is claimed but not supported at all. This patient continues to smoke. There is no real attempt at conservative therapy. Objective testing of this patient's cardiopulmonary status is not documented with a documented history of COPD and CAD along with ongoing smoking. No ABIs or arterial Duplex testing results are submitted. Further, the patient reportedly had a computed tomography angiogram (CTA) but the results were not submitted for this review. 

As per the Milliman Care Guidelines (MCG): Percutaneous Revascularization, Lower Extremity ORG: S-1310 (ISC) MCG Femoral Popliteal BypassORG: S-480 (ISC) MCG, the appropriate and in accordance Generally Accepted Standard of Medical Practice for the treatment of claudication as requested for this patient requires ALL of the following: 

1) Significant functional or lifestyle-altering impairment from pain despite maximally tolerated nonoperative therapy (e.g., medication, smoking cessation, exercise program: usually 3 to 6 months) [Not Met] Rest pain is claimed but not supported at all.  This patient continues to smoke. There is no real attempt at conservative therapy. 

2) Patient has sufficient mobility to benefit from treatment and is without other disease that further precludes walking (e.g., severe heart failure and/or COPD). [Not Met]: Objective testing of this patient's cardiopulmonary status is not documented with a documented history of COPD and CAD along with ongoing smoking. 

3) Documentation of significant occlusive arterial disease (e.g., ABI, imaging, angiography) [Not Met] No ABIs or arterial Duplex testing results are submitted. 

4) Lesion(s) thought to be hemodynamically significant and likely limiting perfusion and are amenable to open or percutaneous intervention [Not Met] The patient reportedly had a CTA: Results were not submitted for this review. 

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 ambulatory surgery, blood vessel procedure is not substantiated.