Peripheral Arterial Disease (PAD) is the result of ischemia (insufficient blood flow) in the lower extremities. The primary cause is atherosclerosis, the slow buildup of fatty plaques (cholesterol, fat, and calcium) inside arteries. This buildup thickens and hardens the arterial walls, narrowing the passage and restricting the flow of oxygen-rich blood to tissues. PAD in the lower extremities can be asymptomatic until the oxygen demand of the lower extremity tissues exceeds its supply. At that point, the typical symptom of claudication is expressed as cramping, pain, or fatigue in muscles (usually of the leg). Claudication is typically triggered by physical activity and usually resolves shortly after rest.
The global prevalence and mortality associated with PAD has increased substantially over the last thirty years. One study estimated a 72% increase in the global prevalence of PAD between 1990 and 2019.1
First line of treatment of PAD involves the treatment with medications and changes in lifestyle (smoking cessation, exercise, dietary improvements). Research indicates that treating early stages of PAD with peripheral vascular procedures can increase an individual’s risk for amputation.4
A recent Office of the Inspector General (OIG) audit identified a group of high-risk vascular physicians who treated at least 94 percent of their Medicare patients for early-stage PAD in office-based laboratory (OBL) settings. This was significantly higher than their peers audited, who treated only 21 percent of their patients for early-stage PAD. The OIG defined early-stage PAD as patients with no other diagnosis codes on claims in the audit year except for intermittent claudication, unspecified peripheral vascular disease, and unspecified atherosclerosis of native arteries of the extremities. Per the audit, in 2023 alone $105M of $548M of payments to physicians for peripheral vascular procedures performed may have been medically unnecessary.5
In significant refractory cases at later stages of disease, peripheral vascular procedures play a role in PAD treatment. Open surgical procedures and percutaneous endovascular procedures both play roles. Open PAD procedures include arterial bypass, which reroutes flow by placement of a graft and endarterectomy, in which the vessel is directly opened and plaque is removed. Percutaneous endovascular procedures attempt to minimally invade the circulatory system by placing specialized catheters that help diagnose and treat without extensive operative time, healing time and complications that can occur with open surgical techniques. The main endovascular procedures performed for PAD include balloon angioplasty, stent placement, and atherectomy. Angioplasty involves inserting a specialized balloon catheter into the blockage site and inflating the balloon, to compress the blockage to the vessel wall, restoring/improving flow. Stent placement is at times performed over the balloon, leaving a rigid tube behind in the wall of the angioplastied vessel. Placement of a stent is designed to retain flow for a more extensive timeframe, in areas with more severe blockage. Atherectomy catheters can be used in especially
refractory blockages. They have a device at the tip designed to rotate and break up the plaque into small particles that can safely circulate.2
Citing a lack of evidence of benefit and potential harm, the Society of Vascular Surgery recommends generally against treating patients with intermittent claudication (IC) and no signs of chronic limb-threatening ischemia (CLTI) with infra-popliteal (below knee) revascularization. Although specific pathology in some cases may support the use of angioplasty, stent placement, and/or atherectomy of the arteries below the knee in treating IC, we should not expect to see a vascular provider using this as primary treatment in the majority of their IC patients.3
Context4 Healthcare (C4H) recommends that payers monitor for providers performing tibial artery endovascular procedures for treatment of IC with high frequency in the OBL setting by evaluating peer comparative reviews and by examining medical records. Monitor your endovascular procedural claims performed for intermittent claudication and identify outlying vascular providers reporting tibial endovascular procedures at significantly higher frequency compared to their peers. Also monitor for providers submitting endovascular procedure claims on an excessively high percentage of patients with early-stage PAD.
C4H offers Provider Outlier Analysis Frequency and Charge Benchmarking Reports to customers licensing the reporting and analytics component of our Medical Payment Integrity solution, that allow our users to identify outliers for all types of procedures, not only IC. Identifying these patterns can prevent your health plan from paying out valuable healthcare dollars for endovascular arterial procedures of the lower leg that may not have been medically necessary.
1. The global burden of peripheral artery disease, Mark A. Eid, MD, MS, et al, New England Society for Vascular Surgery, pp 1119 – 1126, April 2023.
2. Parwani D, Ahmed MA, Mahawar A, Gorantla VR. Peripheral Arterial Disease: A Narrative Review. Cureus. 2023 Jun 11;15(6):e40267.
3. Conte M. et al., Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: Management of asymptomatic disease and claudication, Journal of Vascular Surgery, vol. 61, no. 3S March 2015.
4. Conte M, et al.,Society for Vascular Surgery Clinical Practice Guideline on the management of intermittent claudication: Focused update. Journal of Vascular Surgery, 2025; 82, 303-326.e11
5. Office of Inspector General, Office of Evaluation and Inspections, Audit Report number OEI-01-24-00250, Utilization Trends and Medicare Part B Billing for Office-Based Peripheral Vascular Procedures Raise Questions About Program Integrity, Issued on 05/04/2026
