Diagnosis: peripheral arterial occlusive disease.
Treatment acute patient stay.
The insurer denied coverage for acute patient stay.
The denial is overturned.

This case involves a patient who presented to the emergency department complaining of worsening left lower extremity pain. He indicated his pain has been present for a month. He stated his pain increases with walking and he was having pain with rest. According to the appeal documentation submitted he had previously been seen by vascular surgery with an abnormal pulse volume recording. He does have a past medical history significant for chronic obstructive disease (COPD) as well as Crohn's disease. The physical exam revealed an absent left foot pedal pulse. There was a nonpalpable femoral pulse. The recommendation was made to admit the patient to have him undergo a left endarterectomy and patch angioplasty. The following day he received cardiac clearance and underwent surgical intervention. He was discharged with instruction to follow-up.

The patient had a one-month history of left leg claudication and known peripheral arterial occlusive disease. The patient had outpatient non-invasive imaging with Pulse Volume Recording. This test was abnormal and thus patient was scheduled for an outpatient angiography. However, he presented to the emergency department with left leg rest pain, which was a clinical worsening than his previous claudication. Given the change in the patient's symptomatology, a CT (compute tomography) angiogram was ordered, and it revealed critical left common femoral occlusive disease, best treated with surgical revascularization.

Given his multiple co-morbidities, he had cardiac clearance, and following this, on the same day, he underwent a left femoral endarterectomy with patch angioplasty.

He did well and was discharged on postoperative day 1.

This patient was managed appropriately, as rest pain is a marker for the threat of limb loss and is much more serious than claudication. Given the risk of limb loss, the ordering of angiography and immediate surgery was indicated.

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 acute patient stay is overturned. Medical necessity is substantiated.