Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Surgery to open a blocked artery in left leg.
The insurer denied Surgery to open a blocked artery in left leg. 
The denial is upheld. 

The patient is a female with multiple sclerosis, high blood pressure, hyperlipidemia, a blood clot in the left lower extremity, on Eliquis, who presented to her provider for complaints of significant pain on ambulation after 3 blocks in the left lower extremity. The patient has sciatica symptoms on left lower extremity treated by pain management. The patient was noted to have 2 plus (+) dorsalis pedis (DP) and posterior tibial (PT) pulses in the right lower extremity and 1+ DP and PT pulses in the left lower extremity, with less than(< ) 2.5 sec capillary refill. The extremity was warm to touch with non-pitting edema in the bilateral lower extremities.
An arterial duplex exam of the lower extremities performed, was interpreted as: "No significant elevation of peak systolic velocity is seen in the right lower extremity to suggest a hemodynamically significant stenosis. The right lower extremity waveforms demonstrate a multiphasic flow pattern. Significant elevation of the peak systolic velocity is seen in the left lower extremity to suggest a hemodynamically significant stenosis in the popliteal artery. The left lower extremity waveforms demonstrate a multiphasic flow pattern." "Conclusions: No hemodynamically significant stenosis are identified in the right lower extremity arterial system. Hemodynamically significant stenosis are identified in the left lower extremity arterial system in the popliteal artery greater than 50%."
The provider noted "Due to symptoms reported, physical exam (PE), and ultrasound (US), recommend angiogram. Patient will require medical clearance from primary care physician (or provider) (PCP)." The patient was then scheduled for a left lower extremity angiogram, revascularization femoral popliteal artery(s), and revascularization tibial, peroneal artery.
At issue is the medical necessity of Surgery to open a blocked artery in left leg.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Surgery to open a blocked artery in left leg is not medically necessary for this patient.
The diagnosis of the patient's left lower extremity arterial disease is made from the arterial duplex lower extremity study performed, which was interpreted as, "Conclusions: No hemodynamically significant stenosis are identified in the right lower extremity arterial system. Hemodynamically significant stenosis are identified in the left lower extremity arterial system in the popliteal artery greater than 50%." However, careful review of the left lower extremity ultrasound data demonstrates a maximum peak systolic velocity (PSV) of 113 centimeter (cm) /second (s) in the distal popliteal artery with a multiphasic waveform. A peak systolic velocity of 113 cm/s in the popliteal artery is not hemodynamically significant and is consistent with less than 20% stenosis using standard arterial duplex testing criteria. [1] The patient does not have significant left lower extremity arterial disease based on the data from her arterial duplex lower extremity study report. There is no objective data in the documentation demonstrating her lower extremity arterial disease. The recommended treatment is not medically necessary.
Therefore, the requested health service/treatment of Surgery to open a blocked artery in left leg is not medically necessary.