Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve left heart catheterization with an out-of-network tertiary level of care provider.
You asked the Plan to pre-approve catheterization procedure. You say that the in-network facility did not have the capability to care for you, so they transferred you to this provider who provided the necessary care to improve your health. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network non-tertiary level provider.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 catheterization procedure. Our reviewer says that you meet the Medicare criteria for a network lock-in exception for this service. Our physician reviewer found you had severe complications with late stent thrombosis after prior knee surgery. Your atherosclerotic coronary artery disease is complex, and you have multiple stents. Medically it is reasonable, based on your condition and test findings, to move forward with a cardiac catheterization to reassess coronary anatomy for evidence of restenosis of any one of a number of possible stents you have had placed before undergoing a repeat non-cardiac surgical procedure. If an intervention is required based on the results of the catheterization, it may be quite complex, and you may not tolerate it well. The various percutaneous and open surgical options for this support at a tertiary facility are much greater with specifically trained staff and would make for a safer procedure, given the higher risks and possible poor outcomes of a repeat intervention. At the current time, the physician at the in-network facility are not in favor of this invasive catheterization evaluation and based on the records provided, so far no in-network cardiologist has seen you or agreed to do the catheterization yet, while the physician who performed your prior catheterization at the requested facility is
recommending and willing to do it with the appropriate tertiary backup in place for any complications that
might arise. As such, based on your very complex prior history, severe potential outcomes, and severe possible
complications as well as the best continuity of care, you would be best managed by having cardiac
catheterization as the requested out-of-network tertiary facility and by your prior treating cardiologist there.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of catheterization procedure have been met. Therefore, we decided that the Plan
has to pre-approve left heart catheterization with an out-of-network tertiary level of care provider.
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.