Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Peripheral Arterial Disease

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

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

The denial is upheld

 
This is an adult male who is being evaluated for treatment of PAD (Peripheral Arterial Disease) and right leg claudication symptoms. The request was previously denied noting the insurer has denied coverage for outpatient surgery (37220, 37221, 37224, 37226, 37228) x 1, as not medically necessary. The Final Adverse Determination letter stated, "The patient has pain in the legs. Records do not show that the patient has clogged blood vessels as shown by special tests called invasive imaging tests. The patient requested a main surgery to fix clogged vessels which already includes multiple steps. The physician requested additional steps which are already included in the main surgery. Records do not show that the patient has tried and failed at least three months of conservative treatment. The requested service is denied based on criteria from Turning Point guidelines named Peripheral Arterial Revascularization and Medical Record Documentation - GN-1002." 

Both venous and arterial exams were done. The venous was negative for deep vein thrombosis (DVT). Arterial demonstrated an occluded right SFA -(superficial femoral artery). He was started on Plavix, which helped. The patient does complain of cramping in the right calf. He is on his feet all day at work at a car dealership. It is also noted the patient is an everyday pack a day smoker for the last 25 years.

According to the records provided for review, the patient is an everyday pack a day smoker for the last 25 years. As the patient continues to smoke and has not tried conservative therapy, the health care plan acted reasonably and with sound medical judgement and in the best interest of the patient.      

The outpatient surgery (37220, 37221, 37224, 37226, 37228) x 1 is not considered medically necessary for this patient. 

Per Turning Point Policy; Peripheral Artery Revascularization, revascularization may be necessary after three months of guideline-directed therapy. 

Further, as per Turning Point Policy Number: GN-1002; Policy Name: Medical Records Documentation; medical records should contain accurate and thorough documentation. 

Contradicting medical records were submitted. It was noted this patient was documented as having "Rest Pain". However: This patient's ankle-brachial index (ABI)  and level of Peripheral Arterial Disease (PAD) are both consistent with Claudication Range and not ischemic range. Further, the patient is an everyday pack a day smoker for the last 25 years and has not tried conservative therapy. Given the above, the outpatient surgery (37220, 37221, 37224, 37226, 37228) x 1 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 outpatient surgery (37220, 37221, 37224, 37226, 37228) x 1 services is not substantiated.