Diagnosis: Left leg pain
Treatment: Vascular Surgery (35656 x 1), Bypass graft, with
other than vein
The insurer denied: Vascular Surgery (35656 x 1), Bypass graft, with other than vein
The denial is upheld.

The patient is an adult male. He is being evaluated for ongoing left leg claudication. The patient is status post left to right cross-over fem-fem bypass graft. As of a clinic note dated last month, the patient is still smoking.

The requested health service is not medically necessary.

This patient is noted to have left leg claudication symptoms. As per the MCG (Milliman Care Guidelines) Guidelines: Femoral Popliteal Bypass ORG: S-480 (ISC) MCG (1), as well as according to the medical literature cited below, the appropriate the treatment of claudication as requested for this patient, which would be in accordance with generally accepted standards of medical practice, includes at least significant functional or lifestyle-altering impairment from pain despite maximally tolerated non-operative therapy (e.g., medication, smoking cessation, exercise program: usually 3 to 6 months). This is not met in this case. The patient's specific limitation of ADLs (activities of daily living) is not documented. A physician-monitored trial of conservative therapy is not documented. Importantly, even after being treated for very significant peripheral arterial disease, this patient continues to smoke. This patient continues to smoke without any well-documented trial of conservative therapy. Importantly, it is documented that his patient has "Mild or moderate disease that does not limit activities." Surgery may be avoided with smoking cessation and conservative therapy. Ongoing smoking is associated with accelerating graft failure.