Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Peripheral vascular disease.
Treatment:  Peripheral angiogram leg arteries with intervention and stenting.

The insurer denied coverage for peripheral angiogram leg arteries with intervention and stenting.  The denial is overturned.

This patient has a history of hypertension, hyperlipidemia, and peripheral vascular disease (PVD), who was requesting coverage for treatment of leg arteries, peripheral angiogram with intervention and stenting. The lower arterial assessment noted the patient complained of bilateral calf and foot cramping during exertion that was relieved with rest and elevations. The patient endorsed that claudication progressively worsened throughout the day with movement. The report noted an incisional scar on the right medial ankle from femoropopliteal bypass surgery. On the right foot, the patient had yellowing, clubbed toenails with a stage II pressure wound on the middle toe with slough and stage II pressure wound on the third toe with eschar. The report indicated that he was prediabetic. Findings on the peripheral arterial duplex scan noted the right superficial femoral artery was occluded with popliteal artery above the knee and behind the knee occluded. Vein graft occluded at the short segment after proximal anastomosis. On the left lower extremity, the common femoral artery Peak systolic velocity (PSV) was 37 centimeters per second (cm/s) and aneurysmal at 2.67 cm in diameter. The superficial femoral artery was occluded with popliteal artery aneurysmal, partially thrombosed, with monophasic waveform and a diameter of 2.56 cm.

The progress notes stated the patient came in for vascular consultation and complaint of bilateral claudication with arterial duplex showing bilateral peripheral arterial disease (PAD). Computed tomography (CT) angiogram demonstrated significant bilateral atherosclerotic disease. The patient developed an ulcer over the right lateral ankle and was agreeable to endovascular evaluation. His body mass index was 36.62. An addendum was added stating that the patient had known PAD status post-surgical bypass and was now with nonhealing ulcer, severe constant pain, and noninvasive testing showing severe occlusive PAD on duplex and CT angiogram. He was most recently examined regarding his PVD. He underwent duplex scanning of the lower extremities bilaterally, which found consistent abnormalities with claudication. He had a wound on his right ankle that was nonhealing.  

The information provided for the review confirmed that the patient had peripheral vascular disease and evidence of wounds to the lower extremities that were nonhealing with notation that the potential for infection and osteomyelitis was possible. The patient's wound had not improved with the current size measuring 1 cm in diameter by 0.3 cm deep overlying the right lateral malleolus. The wound had fibrous and necrotic base with the situation greatly complicated by the peripheral arterial disease. 

Conservative care failed to improve the wound as noted by the treating physician, and it was the physician's opinion the vascular intervention was necessary to facilitate healing. Given these findings, the proposed treatment is supported. As such, the treatment of leg arteries with peripheral angiogram with intervention and stenting is medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for treatment of leg arteries, peripheral angiogram with intervention and stenting is substantiated.