Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic venous insufficiency, hypertension, alcohol abuse, ischemic cardiomyopathy, ST elevated myocardial infarction (STEMI), and pyoderma gangrenosum

Treatment: Vascular surgery/open revascular, 01-unit, open revascularization with stent placement

The insurer denied coverage for vascular surgery/open revascular, 01-unit, open revascularization with stent placement

The denial is upheld.

This is a male with a history of chronic venous insufficiency, hypertension, alcohol abuse, ischemic cardiomyopathy, STEMI, and pyoderma gangrenosum. He had a diagnostic venogram which revealed bilateral iliac vein compressive physiology. Treatment was deferred due to pyoderma gangrenosum. He also had an acute myocardial infarction (MI) and was hospitalized. Percutaneous coronary intervention (PCI) was needed. The treating provider is requesting coverage for stenting of the iliac vein compression and superficial venous treatment to assist with healing of leg wounds.

"Vascular physicians have become aware of the occasional patient with otherwise-unexplained extremity swelling and/or pain but without a deep vein thrombosis (DVT) history who is subsequently found to have an iliac vein abnormality. These 'lesions' have been hypothesized to elevate ambulatory venous pressures and thereby produce lower-extremity symptoms, increase the risk of initial and recurrent DVT episodes, and increase the risk of treatment failure with medical and endovascular therapies for thrombotic and non-thrombotic venous conditions. As a result, many practitioners now actively seek iliac venous obstructive 'lesions' when evaluating patients with known or suspected venous disease. However, for many patients, it continues to be unclear what degree of obstruction to venous blood flow is being caused by such lesions, how clinically significant they are, how much emphasis should be placed on identifying them, and when they should be treated." (Birn, J., & Vedantham, S. 2015)      

"Although, clinically, MTS is not a common cause of DVT, cadaveric and radiographic studies have reported a high incidence of compression of the left iliofemoral vein by the right common iliac artery." (Mangla, A., & Hamad, H. 2022)

"The approach to diagnosis and treatment depends upon whether venous thrombosis is present. When the diagnosis is highly suspected based upon clinical features or noninvasive vascular imaging, a definitive diagnosis is established using intravascular ultrasound (after removal of thrombus, if necessary). Minimally invasive treatment (angioplasty and stenting) of the venous lesion relieves outflow obstruction and provides immediate relief of symptoms with good long-term patency rates. For those with venous thrombosis, rates of post-thrombotic syndrome are reduced with endovascular treatment." (Mousa, A.Y. 2022)       

Before vein compression syndrome is treated (May-Thurner); a trial of conservative therapy is performed (not well documented with this patient) and very likely any superficial venous disease is treated initially. However, this patient needs updated venous duplex with the latest documented now over one year out of date. The denial of the requested services was appropriate, in this case.

This patient is described as having Pyoderma Gangrenosum. Reported stenting is needed for healing. However: As per serial clinic visits: this lesion is described as being smaller. No actual wound measurement was submitted. For any future appeals: Updated wound description is needed now along with ideally with wound photographs. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for vascular surgery/open revascular, 01-unit, open revascularization with stent placement is upheld.  Medical Necessity is not substantiated.