202212-156616
2023
Empire Healthchoice Assurance Inc.
Indemnity
Blood Disorder
Surgical Services
Medical necessity
Upheld
Case Summary
Diagnosis: Peripheral Arterial Disease (PAD)
Treatment: Vascular surgery (angioplasty) procedure codes 37220, 37221, 37222, 37223, 37224, 37225, 37226, 37228, and 37229, and inpatient stay
The insurer denied: Vascular surgery (angioplasty) procedure codes 37220, 37221, 37222, 37223, 37224, 37225, 37226, 37228, and 37229, and inpatient stay
The denial is upheld
The patient is a male with a remote history of smoking having quit more than 30 years ago. The patient underwent right common femoral artery endarterectomy and right external iliac artery stenting and right proximal superficial femoral artery (SFA) stenting for disabling right leg claudication. The patient is maintained on Plavix (but is not on a statin for unclear reasons despite having a documented mild dyslipidemia and a history of peripheral arterial disease [PAD]).
Based on the answer to question #1, both the requested procedure codes and inpatient medical stay are not medically necessary for this patient at this time. The issue that led to the health plan's denial is that conservative therapy, which in the case of claudication is an exercise program and sometimes medication such as cilostazol has not been completed for this patient from the office visit. The provider stated in his addendum that the patient "has tried walking and exercising for over 6 months but this has not helped." It is unclear to me what form of exercise program the patient has engaged in as it is not described in the provider's documentation. Also, it is not chronologically possible for the patient to have engaged in a program for 6 months from the office visit.
The most recently published American Heart Association/American College of Cardiology (American Heart Association [AHA]/American College of Cardiology [ACC]) guidelines on the management of patients with lower-extremity PAD include 4 recommendations supporting exercise therapy for patients with PAD. The AHA/ACC guidelines gave supervised exercise treadmill training a Class I recommendation supported by a Level of Evidence A on the basis of multiple randomized clinical trials showing the efficacy of supervised exercise treadmill training to improve claudication onset time (COT) or distance (COD), peak walking time (PWT) or peak walking distance (PWD), and other clinically meaningful functional outcomes.
Endovascular intervention for the right lower extremity is not warranted at this time.