Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization, endovascular, open or percutaneous, 
femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes 
angioplasty within the same vessel, when performed (37227), revascularization, endovascular, open or 
percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same 
vessel, when performed (37225), revascularization, endovascular, open or percutaneous, tibial, peroneal artery, 
unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the 
same vessel, when performed (37231) and revascularization, endovascular, open or percutaneous, tibial, 
peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when 
performed (37229). 
 You asked the Plan to pre-approve in-office procedures. You say that the requested procedures are medically 
necessary. The Plan denied your request. The Plan says the requested procedures do not meet criteria. 
 
The Plan must follow 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 in-office procedures. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee presented urgently for extensive left lower extremity DVT.  The plan 
was for anticoagulation and referral for hypercoagulable workup which has not yet been completed. There is no 
documentation that the enrollee was having lifestyle limiting claudication prior to his extensive DVT. No signs 
of limb threat are documented. In the absence of lifestyle limiting claudication that is resistant to conservative 
efforts, and in the absence of limb threat, cannot overturn the health plan determination on the basis of medical 
necessity, particularly in the setting of recently identified extensive DVT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of in-office procedures have not been met. Therefore, we decided that the Plan 
does not have to pre-approve revascularization, endovascular, open or percutaneous, femoral, popliteal 
artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the 
same vessel, when performed (37227), revascularization, endovascular, open or percutaneous, femoral, 
popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed 
(37225), revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; 
with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when 
performed (37231) and revascularization, endovascular, open or percutaneous, tibial, peroneal artery, 
unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed 
(37229).