Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approverevascularization services. We decided that the Plan does not have to pre-approvestenting services. You asked the Plan to pre-approverevascularization services. The Plan says that the documentation does not show medical necessity.We decided that the Planhas to pre-approverevascularization services. 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.The file shows that revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty (CPT Code 37224) was requested. 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 services. Our physician reviewer found that the requested services normally would not be recommendedas the most recent available duplex demonstrated no significant lower extremity arterial disease.  However, as the enrolleeis already undergoing the risks attendant with left heart catheterization, it would not be unreasonable to image the lower extremities at the same time,considering the enrollee'sleg complaints and abnormal exercise study last year.  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 services have been met.Therefore, we decided that the Plan has to pre-approverevascularization services. We also decided that the Plandoes not have to pre-approvestenting services.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.The documentation shows that a transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed (CPT Codes 37238 and 37239) was requested. 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 stenting services. Our physician reviewer found that the requested services are for venous stenting and there is no documentation that these procedures are indicatedor even being considered. Therefore, the requested stent services are not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of stenting services have not been met.Therefore, we decided that the Plan does not have to pre-approvestenting services.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 happenoften. If we decide to open the case again, we will send you a letter.