Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Subacute ischemia to the left lower extremity
Treatment is Current Procedural Terminology (CPT) code 37227 revascularization, endovascular, open or percutaneous, femoral/popliteal artery, unilateral; with transluminal stent placements and atherectomy, includes angioplasty within the same vessel, when performed
The insurer denied coverage for (CPT) code 37227 revascularization, endovascular, open or percutaneous, femoral/popliteal artery, unilateral; with transluminal stent placements and atherectomy, includes angioplasty within the same vessel, when performed.
The denial is overturned.

The treating provider has diagnosed the patient with subacute ischemia to the left lower extremity. The patient has a medical history of cervical disc disorder, peripheral vascular disease (PVD), hypertension, hypertrophic cardiomegaly, hypertension, hyperlipidemia, and diabetes. The request is for approval of (CPT) code 37227 revascularization, endovascular, open or percutaneous, femoral/popliteal artery, unilateral; with transluminal stent placements and atherectomy, includes angioplasty within the same vessel, when performed.

A progress note indicated the patient presented with subacute severe ischemia to the left lower extremity. The records state that a prior intervention of the left superficial femoral artery had been performed. The records offer no description of what symptoms are present resulting in the statement that the patient presented with "subacute severe ischemia." Past medical history reports "leg pain right leg" (pattern of pain not described; it is not possible to discern if the pain was characteristic of arterial disease or of other etiology, such as arthritis or radiculopathy). Past medical history also reports "intermittent claudication," without specifying severity or response to conservative measures, such as exercise training or cilostazol treatment. There were no results of noninvasive testing, such as ankle brachial index (ABI) or arterial ultrasound testing, Computed tomography (CT) angiogram or MR (Magnetic resonance) angiogram are reported. Physical findings documented at that time include only "left foot subacute significant ischemia without tissue loss." There is no description of color, temperature, capillary refill, pulse examination, or noninvasive testing of arterial perfusion.

Per Kansal, A., Long, C. A., Patel, M. R., & Jones, W. S. (2019), "The evolution of endovascular techniques and device technology over the last 20 years has led to an increase in endovascular revascularization procedures, with a subsequent reduction in the performance of open surgical revascularization procedures. Similar to patients undergoing coronary revascularization, endovascular treatment allows patients to return to normal activity more quickly and the risk of complications is markedly reduced when compared with surgical procedures."

Per Vossen, R. J., Vahl, A. C., Leijdekkers, V. J., Montauban van Swijndregt, A. D., & Balm, R. (2018), "Selective stenting in patients with SFAD (superficial femoral arterial disease) shows comparable results in long-term clinical outcomes in patients who were treated with plain PTA (Percutaneous transluminal angioplasty) as well as patients who are selected for stent placement. An approach of selective stenting is justified."                                                         

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the current procedural terminology (CPT) code 37227 revascularization, endovascular, open or percutaneous, femoral/popliteal artery, unilateral; with transluminal stent placements and atherectomy, includes angioplasty within the same vessel, when performed, is overturned. Medical Necessity is substantiated.