Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stenosis of the left distal superficial femoral artery. 
Treatment: Revascularization, endovascular, open tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty. 

The insurer denied coverage for revascularization, endovascular, open tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty

The denial is upheld. 
 
This is a patient who has a history of diabetes, hyperlipidemia, and tobacco abuse. 

The patient presented with complaints of bilateral leg pain and tiredness associated with exertion. An ultrasound arterial duplex of the lower extremities revealed stenosis of the left distal superficial femoral artery (SFA). The provider has recommended a left leg angiogram. This request has been denied coverage for revascularization, endovascular, open tibial, peroneal artery, unilateral, initial vessel, with transluminal angioplasty, as not medically necessary. 

In a Final Adverse Determination letter, the insurer stated that the patient has a stent in the right leg. The left leg SFA has a narrow area of 12 centimeters (cm). Treating a narrow area longer than 10 cm is not considered medically necessary. The requested service is denied based on Clinical UM guidelines, CG-SURG-49: Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities Treatment of Claudication criteria. 

The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient, as the denial was appropriate. This patient did not meet accepted guidelines. 

Revascularization, endovascular, open tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty, is not considered medically necessary for this patient. 

As per the Milliman Care Guidelines (MCG): Percutaneous Revascularization, Lower Extremity ORG: S-1310 (ISC) MCG as well as in the medical literature reviewed and in accordance with generally accepted standards 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 - While this patient claims 1 block claudication: Specific limitations/restrictions of activities of daily living (ADLs) are not documented. A monitored actual physician trial of conservative therapy (usually 6 months documented serially in the medical records) is not documented. This patient continues to smoke 1 pack per day (PPD). It is not sufficient just to tell a patient to exercise. A specific plan needs to be documented along with a follow-up. Importantly: without well documented smoking cessation (Urinary cotinine will be needed) even well placed left sided stenting is likely long-term to fail. 

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 chronic obstructive pulmonary disease (COPD)) - Not Met - Objective testing of this patient's cardiopulmonary status is not documented. This patient has had cardiac stenting and with smoking for 40 years, COPD. Needs formal cardiac and pulmonary assessment documented better. 

3) Documentation of significant occlusive arterial disease (e.g., ankle-brachial index (ABI), imaging, angiography) - Met - Left ABI of 0.43 

4) Lesion(s) thought to be hemodynamically significant and likely limiting perfusion and are amenable to open or percutaneous intervention - Met - See Duplex. 

As all indicated accepted criteria for the medical necessity of the requested service, (revascularization, endovascular, open tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty), were not present in this case, this request is not considered medically necessary for this patient. 

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 revascularization, endovascular, open tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty is not substantiated.