Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve right iliac revascularization. We decided that the Plan does not 
have to pre-approve left lower extremity revascularization.  
 
You asked the Plan to pre-approve right iliac revascularization. You say that these services are medically 
necessary. The Plan says that there is no occlusive disease show in the right iliac artery. 
 
We decided that the Plan has to pre-approve right iliac revascularization.  
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered.   
 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 right iliac revascularization. Our 
reviewer says that right iliac revascularization is medically reasonable and necessary. There is satisfactory 
evidence of a possible ischemic ulcer with evidence of right lower extremity arterial occlusive disease. As the 
patient has a history of diabetes, the ankle brachial index (ABI) may be artifactually elevated. It would be 
reasonable to preapprove codes for intervention on the right lower extremity at all levels including the iliac 
artery as it is not clear what the angiogram will show. As the patient may have an iliac lesion on the right, and 
this leg is significantly symptomatic, it would be appropriate to have the iliac artery intervention preapproved. 
Our physician reviewer found that the enrollees condition meets criteria for coverage of right iliac 
revascularization. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of right iliac revascularization have been met. Therefore, we decided that the Plan 
has to pre-approve right iliac revascularization.  
 
We also decided that the Plan does not have to pre-approve left lower extremity revascularization. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered.  
 
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 left lower extremity revascularization. 
Our reviewer says that left lower extremity revascularization is not medically reasonable and necessary. The 
documentation does not provide satisfactory evidence of an indication for treatment. Our physician reviewer 
found that the enrollees condition does not meet criteria for coverage of left lower extremity revascularization.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of left lower extremity revascularization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve left lower extremity revascularization. 
 
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.