Diagnosis: Peripheral vascular disease.

Treatment: Outpatient ambulatory surgery.

The insurer denied coverage for outpatient ambulatory surgery.

The denial is overturned.

This is the case of a male with peripheral vascular disease that required left lower extremity revascularization. Past medical history was significant for hypertension, heart failure with preserved ejection fraction and concentric left ventricular hypertrophy (LVH) on echocardiography and transient ischemic attack (TIA). He was treated with guideline directed medical therapy including atorvastatin, aspirin, losartan, and amlodipine. The patient presented with complaints of leg cramping, heaviness, and fatigue after walking a few steps. In addition, he reported symptoms of numbness and paresthesia of the lower extremities while trying to sleep at night. Physical examination was significant for diminished hair on the lower extremities and bilateral weak pulses (1/4) at the posterior tibial and anterior tibial positions. Ankle-brachial index (ABI) was 0.7 for the left lower extremity and 0.8 for the right. The patient was referred for lower extremity revascularization and findings revealed 100% popliteal occlusion, mid to distal anterior tibial artery (ATA) occlusion and 100% peroneal artery occlusion. Laser atherectomy with balloon angioplasty was successfully performed.

This patient presented with signs of critical limb ischemia. This is defined by American Heart Association/American College of Cardiology (AHA/ACC) guidelines as a condition characterized by more than two weeks of ischemic rest pain. (1) This patient reported a history of claudication despite being treated with guideline directed medical therapy that included an antiplatelet agent, an angiotensin II receptor blocker, a statin drug and an antihypertensive medication. Symptoms worsened despite medical therapy and physical therapy. After presenting with lifestyle limiting claudication and persistent rest pain for more than a two-week period, he appropriately underwent revascularization. (1, 2). In conclusion, it was medically necessary to undergo outpatient ambulatory surgery with lower extremity revascularization.

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 outpatient ambulatory surgery is overturned. Medical Necessity is substantiated.