Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve angioplasty and stent placement.
You asked the Plan to pre-approve revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (37221), Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (37227), and Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed (37229). You say that you cannot walk and are in intense pain. The Plan denied your request. The Plan says that the enrollee fails to meet Plan guidelines and there is no documented failure of conservative management.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (37221), Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (37227), and Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed (37229). Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has smoked for over 50 years and claudicates at 90 feet. Dorsalis pedis pulse is absent on the right. Arterial duplex demonstrates monophasic flow from external ileac through posterior tibial artery. Simultaneous arteriogram and revascularization is medically reasonable and necessary as defined by Medicare rules. The elements of the coverage rules are satisfied. The requested service is recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (37221), Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (37227), and Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed (37229) have been met. Therefore, we decided that the Plan has to pre-approve angioplasty and stent placement.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.