Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve transcatheter implantation of wireless pulmonary artery pressure 
sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart 
catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary 
artery angiography, when performed (CPT Code 33289). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says that this request is considered investigational; therefore, not medically necessary. 
 
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 the service. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the patient has complex cardiopulmonary disease with congestive heart failure, ischemic heart 
disease, prosthetic aortic valve stenosis, pulmonary hypertension and sleep apnea requiring BiPAP therapy. 
The patient remains symptomatic and had a recent hospitalization for congestive heart failure which was 
complicated by renal insufficiency owing to their complex cardiopulmonary disease and complex diuretic 
regimen. It has been difficult to manage the patient's fluid status in the setting of their complex valvular lesions 
and renal insufficiency for which the patient is being followed by nephrology. Based on published randomized 
clinical trial data (1,2) they would benefit from implantation of CardioMEMS device to help manage her fluid 
status and this has been shown to decrease recurrent hospitalizations for CHF and improve quality of life and 
symptoms in just this type of patient. The device is medically necessary and appropriate for this indication and 
meets the CMS criteria as safe, effective, and not experimental for the patient's condition with published 
randomized data showing its effectiveness for this type of patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have been met. Therefore, we decided that the Plan has to pre-
approve transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic 
monitoring, including deployment and calibration of the sensor, right heart catheterization, selective pulmonary 
catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when 
performed (CPT Code 33289).  
 
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.