Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arterial insufficiency.
Treatment: 37228 x1, 37224 x1,37226 x1 
The insurer denied: 37228 x1, 37224 x1,37226 x1 
The denial is overturned.

The patient is an adult male. He has a history of early onset atherosclerotic cardiovascular disease (ASCVD). He has undergone prior coronary stenting and prior bilateral "kissing" iliac stents. A non-invasive vascular study demonstrated mild left leg arterial insufficiency with ABI (Ankle Brachial Index) 0.90. That study also demonstrated elevated velocity in the left common iliac stent at 320 centimeters per second. The patient had a follow up vascular office visit 4 months ago. At that time, he reported increasing symptoms of his left leg, to the point where he had to "drag" the leg. Office ABI (Ankle Brachial Index) testing now demonstrated ABI (Ankle Brachial Index) 0.50. The vascular surgeon has proposed left leg angiogram with possible intervention. The stated purpose of the angiogram is to preserve patency of the left iliac stent. Coverage was denied by the health plan on the basis that the records (1) lack documentation of 
imaging confirming blockage or occlusion; and (2) lack documentation of a specific surgical plan for intervention. The denial is being appealed.

The requested health service is medically necessary.

This patient exhibits evidence of progressive arterial insufficiency of the left leg. The study from last year suggested that the patient had stenosis of the left common iliac stent, but his ABI (Ankle Brachial Index) was well preserved at 0.90. However, 4 months ago, evaluation demonstrated declining ABI (Ankle Brachial Index) at 0.50, with severe symptoms compatible with claudication. This clinical picture is concerning for progressive stenosis of the left commonly stent. Because of symptomatic arterial insufficiency and the need to preserve patency of the stent, angiography is medically necessary. Depending on the angiographic findings, intervention for the stent and other 
lesions may be necessary. This specific intervention can only be determined after the diagnostic angiographic images are obtained. It is routine for the practitioner to seek approval for multiple different possible interventional procedures, because the specific intervention cannot be definitively known in advance. 

Coverage for the service was denied by the health plan because the records (1) lacked documentation of imaging confirming blockage or occlusion and (2) documentation of a specific plan for intervention. However, it is standard of care to begin the angiographic procedure with a diagnostic angiogram. This diagnostic angiogram will provide information about any blockage or occlusion. Based on those findings, the vascular surgeon can proceed with a specific intervention at the same setting. This strategy is effective and eliminates the need for a second interventional procedure.
It is not reasonable to expect the requested information in advance of the angiogram. Obtaining this information in advance of the angiogram could theoretically be done by obtaining a CTA (Computed Tomographic Angiography). However, in a patient with a high likelihood of having stenosis or occlusion, CTA (Computed Tomographic Angiography) represents an unnecessary diagnostic procedure. It is not medically necessary to obtain such a study prior to the diagnostic angiogram. Requiring such a study in advance would also increase overall burden of care, because the CTA (Computed Tomographic Angiography) cannot be used to perform therapeutic intervention, unlike the catheter angiogram proposed by the vascular surgeon in this case.