Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Aortoiliac occlusive disease and mural thrombus
Treatment: Blood vessel surgery and hospital admission
The insurer denied blood vessel surgery and hospital admission.
The determination is overturned.

The patient presented with severe aortoiliac occlusive disease and mural thrombus. He has a history of embolization and occlusion to his left femoral artery. Per the provider, he is at risk for future embolization and presented to the hospital for endovascular exclusion of his aorta and iliac artery thrombus. In the recovery room, the patient as noted to have gross hematuria from his foley. Upon evaluation the next day, he was noted to have continued gross hematuria and a urology consultation was requested. An 18 F [French] Coude catheter was inserted and was administered oxybutinin for bladder spasms. The catheter was irrigated overnight and the patient was subsequently discharged. At issue is the medical necessity of an inpatient stay.
The patient was admitted for an extensive mural thrombus in his aorta and iliac arteries. He has a history of prior distal embolization and is at risk for future embolization and threatened limb loss. Lining of the aorta and iliac arteries with an endovascular graft (as was performed) is the current standard of care in the vascular surgery community and strongly supported by the peer reviewed literature. Typically, an overnight stay is required for this type of procedure if there are no complications. In this case, the patient appeared to have traumatic foley placement which resulted in gross hematuria. This required a urology consultation, replacement of the Foley catheter and bladder irrigation. The gross hematuria and the physicians' actions required to stabilize it warranted an overnight stay. There is sufficient documentation to deem the entire inpatient hospitalization as well as the aortic repair medically necessary based on the peer reviewed literature.
Serra and colleagues described the effects and morbidity of aortic mural thrombus, also known as "shaggy aorta". They wrote that Shaggy aorta (SA) depicts the severe aortic surface degeneration, extremely friable, and likely to cause spontaneous peripheral and visceral embolization or during catheterization, aortic manipulation, surgery, or minimally invasive procedures. This study aims to provide the most accurate and up-to-date information on this disease. Potentially eligible studies to be included were identified by searching the following databases: Central Library, ClinicalTrials.gov, Medline, and CINAHL[Cumulative Index to Nursing and Allied Health Literature]) , using a combination of subject headings and text words to identify relevant studies: (Shaggy aorta) or (aortic embolization) or (aortic embolism) or (aortic thrombus) or (aortic plaque). From a total of 29,111 abstracts, and after applying inclusion and exclusion criteria, we considered 60 studies for inclusion in this review. Appropriate measurement and assessment of the aortic wall are pivotal in the modern era, in particular when percutaneous procedures are performed, as SA has been identified as an independent risk factor for spinal cord injury, mesenteric embolization, and cerebral infarction after endovascular aortic repair. Furthermore, SA increases the rate of cerebral complications during transcatheter aortic valve implantation. In conclusion, prompt diagnosis of SA syndrome and appropriate guidelines on the management of these conditions may help physicians to better assess the patient risk and to minimize the dreadful-related complications.