Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Iliac Vessel Blockage

Treatment: Ambulatory surgery outpatient procedures 37226 x1, 37224 x1, and 37228 x1 date of service (DOS) to be determined

The insurer denied coverage for ambulatory surgery outpatient procedures 37226 x1, 37224 x1, and 37228 x1 date of service (DOS) to be determined

The denial is upheld 

The insurer has denied coverage for ambulatory surgery outpatient procedures 37226 x1, 37224 x1, and 37228 x1 date of service (DOS) to be determined. In their Final Adverse Determination letter, they write that the records show that the patient's blockage is one vessel (Iliac), the procedures that were requested are for different vessels. The procedure requested is included in another procedure and cannot be billed separately. 

The patient's medical records indicate that the patient has symptoms suggestive of claudication with no symptoms suggesting limb threatening or critical limb ischemia. There are no ulcers, skin breakdown or non-healing wounds of either foot. The treating provider has obtained imaging demonstrating that the patient has a "single level" common iliac occlusion. The treating provider has requested treatment of the femoral-popliteal and tibial arteries. Imaging affirmatively demonstrates the absence of disease at the femoral popliteal or tibial levels. The procedures have been denied. The treating physician requests an expedited review, stating that a review requiring over 72 hours will cause grave risk to the patient.

The computed tomography (CT) angiogram affirmatively showed absence of disease in the femoral popliteal and tibial arteries. There is no cogent medical rationale for performance of the requested procedures. Treatment of these vessels, where there is no evidence of disease, would be a clear departure from accepted standards of care. 

"Peripheral arterial disease (PAD) continues to grow in global prevalence and consumes an increasing amount of resources in the United States health care system. Overall rates of intervention for PAD have been rising steadily in recent years. Changing demographics, evolution of technologies, and an expanding database of outcomes studies are primary forces influencing clinical decision making in PAD. The management of PAD is multidisciplinary, involving primary care physicians and vascular specialists with varying expertise in diagnostic and treatment modalities. PAD represents a broad spectrum of disease from asymptomatic through severe limb ischemia. The Society for Vascular Surgery Lower Extremity Practice Guidelines committee reviewed the evidence supporting clinical care in the treatment of asymptomatic PAD and intermittent claudication (IC). The committee made specific practice recommendations using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system. Emphasis is placed on risk factor modification, medical therapies, and broader use of exercise programs to improve cardiovascular health and functional performance" (3).                                                         

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 ambulatory surgery outpatient procedures 37226 x1, 37224 x1, and 37228 x1 date of service (DOS) to be determined is not substantiated.