Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve Insertion of new or replacement of permanent pacemaker with 
transvenous electrode(s); atrial and ventricular (33208), Pacemaker, dual chamber, rate-responsive 
(implantable) (C1785), Pacemaker, dual chamber, non rate-responsive (implantable) (C2619), Lead, 
pacemaker, transvenous VDD single pass (C1779) and Lead, pacemaker, other than transvenous VDD single 
pass (C1898) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that that the enrollee does not meet criteria for coverage of these 
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.  
 
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 these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. You have obtained 
authorization for electrophysiologic study to determine the level of atrioventricular block. You have indicated 
in your plan that if the level of block is infra-His, therefore mandating pacemaker implant, you will then 
proceed accordingly immediately following completion of the electrophysiologic study. If, instead, the 
electrophysiologic study does not show infra-His block, then your plan is to follow the patient clinically 
without implantation of a pacemaker. This is reasonable, and your plan for implantation of the pacemaker is 
predicated on the electrophysiologic study result. Your plan is to try to carry out both procedures consecutively 
at the same sitting if the pacemaker proves necessary. In summary, the evidence would suggest that it is 
reasonable and appropriate to allow the option of pacemaker implantation following the electrophysiologic 
study if mandated by the results of the electrophysiologic study in the clinical management of this patient. Our 
physician reviewer found that the enrollee's condition meets criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and 
ventricular (33208), Pacemaker, dual chamber, rate-responsive (implantable) (C1785), Pacemaker, dual 
chamber, non rate-responsive (implantable) (C2619), Lead, pacemaker, transvenous VDD single pass (C1779) 
and Lead, pacemaker, other than transvenous VDD single pass (C1898) for the enrollee.  
 
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.