Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for all codes requested for vascular embolization and angiography.
You asked the Plan to pay for this service. You say that the requested services are medically necessary. The Plan denied your request. The Plan says the Plan approved those codes necessary for prostatic artery embolization. The additional codes requested are not necessary. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for vascular embolization and angiography as part of prostate artery embolization. The following codes were requested:
Code 37242 - Vascular embolization or occlusion, arterial, other than hemorrhage or tumor. The general guidance for this code is that it is used for occlusion of artery (other than hemorrhage or tumor) with radiological supervision and interpretation, road mapping, and imaging guidance. Code 75625 - Procedures of the aorta and arteries. In this procedure, the provider performs imaging supervision and interpretation for abdominal aortography with serialography. Code 75710 - Procedures of the aorta and arteries. The general guidance for this code is that it is used for radiological supervision and interpretation of imaging of artery of one arm or leg. Code 75726 - Procedures of the aorta and arteries. Involves the selective catheterization of the celiac or superior mesenteric arteries. The general guidance for this code is that it is used for radiological supervision and interpretation of imaging of abdominal artery.
The Maximus Physician Reviewer determined that the enrollee has benign prostatic hyperplasia (BPH) and lower urinary tract symptoms.
Vascular embolization and angiography services (abdominal, extremity, and visceral angiographies) are medically necessary as part of a prostate artery embolization. The Plan requested a reopen and argues the denied codes are redundant and/or unrelated to embolization of the prostate artery. The Plan notes that the approved codes covered the placement of catheters in the 1st, 2nd, and 3rd order abdominal, pelvic, or lower extremity arterial branches within a vascular family. The medical records show the enrollee is a 79-year-old man with a diagnosis of benign prostatic hypertrophy (BPH) who previously underwent two minimally invasive surgical procedures. The provider writes that the enrollee is a reasonable candidate for prostate arterial embolization to improve his symptoms and quality of life, as his symptoms had returned despite invasive treatments.
The Plan determined that they would cover the following:
Code 37243 x 2 - Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction, Code 36245 x 2 - Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family, Code 36246 x 2 - Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family, Code 36247 x 2 - Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family, Code 36248 x 2 - Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate), Code 76937 x 2 - Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure), Code 99152 x 2 - Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older, Code 99153 x 2 - Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service) Our Medical Director has determined that the Plan is correct in this case. The Plan appropriately approved the necessary codes for prostatic artery embolization. Additional codes are not needed in this case. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for vascular embolization and angiography as part of prostate artery embolization for the enrollee.