Appeal type: Medical necessity
Decision: Overturned

Diagnosis: peripheral arterial disease
Treatment: vascular procedure (37229 x 1)
The insurer denied coverage for vascular procedure (37229 x 1)
The denial is overturned

This case involves an adult male diagnosed with peripheral arterial disease (PAD), diabetes, hypertension, and gastroesophageal reflux disease (GERD) who had initially presented to the cardiologist office for follow-up regarding PAD.  At the time of the visit, the patient reported feeling at baseline, with mild chest tingling that was positional in nature. He claimed to not walk well, was severely limited by leg pain and fatigue, and had a known history of heart valve replacement twice, and a pacemaker. He was taking multiple medications with his examination findings noting a body mass index of 26.43, with otherwise stable vital signs. While the majority of his examination was relatively unremarkable, the patient had absent dorsal pedis (DP) pulses and faint posterior tibial (PT) pulses. The plan of care at that time included starting aspirin 81 mg (milligrams), continuing statins, and having the patient undergo a diagnostic unilateral peripheral angiogram with or without peripheral intervention with angioplasty or stenting, which was subsequently scheduled and completed without complication. The procedure report noted mild to moderate right superficial femoral artery disease with mild right popliteal artery disease, severe right infrapopliteal disease, and a three-vessel runoff on the right. The patient underwent a successful atherectomy and angioplasty of the right distal anterior tibial artery stenosis with plans to continue optimal medical management and risk factor modification.  

The treating physician stated that the patient was previously diagnosed with peripheral arterial disease (PAD), when he underwent multiple tibial and iliac artery revascularization procedures. Several months later he had worsening lower extremity ischemic pain. The patient was checked for neuropathy at the time of the visit, which came back negative. He followed up with his primary care physician to rule out other causes. The treating physician stated that the patient practiced conservative methods such as weight loss, dietary changes, exercise, leg elevation, and pharmacotherapy for around 6 months. However, symptoms continued to progress aggressively to the point of having pain during rest.  

At his last visit the patient had absent DP pulses and faint PT pulses, which is a high clinical indication for peripheral arterial disease. The suspicions were confirmed with 70-80 percent (%) distal blockages. These were subsequently treated with the procedure on that date. Since then, the patient reported great improvement in the right leg and was eager to have the left leg treated as well.

Current medical literature notes that lower extremity revascularization (LER) is a common treatment in patients with peripheral artery disease (PAD).  The information provided for the review noted that the patient had a longstanding history of peripheral arterial disease affecting his lower extremities and despite conservative methods he remained symptomatic and had a progression of symptoms.  He reported resting pain, and his exam findings were absent of DP pulses and faint PT pulses.  Based upon these findings, it was appropriate to address the symptoms to prevent permanent damage.  

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 vascular procedure (37229 x 1) is substantiated.