Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization, endovascular, open or percutaneous, 
iliac artery, unilateral, initial vessel; with transluminal angioplasty (37220) revascularization, endovascular, 
open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes 
angioplasty within the same vessel, when performed (37221) 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, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the 
same vessel, when performed (37229). 
 
You asked the Plan to pre-approve the in-office vascular surgery. You say that you believe the services are 
medically necessary. The Plan denied your request. The Plan says this request is not medically necessary for 
your condition. 
 
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 the in-office vascular surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a history of arthritis requiring the use of a walker. The only 
area of occlusive disease identified on objective vascular studies is a possible stenosis in the distal right 
superficial femoral artery which would not explain the enrollees left thigh symptoms. On the side of the 
enrollee's symptoms, they have a normal ABI and no evidence of arterial occlusive disease. The enrollee has 
palpable pedal pulses bilaterally. It is documented that the enrollee underwent sclerotherapy/ablation of the 
right lower extremity for this condition, a treatment that would be inappropriate/contraindicated if they had 
significant peripheral artery disease on that side. Review of the medical record would suggest that it is unlikely 
the enrollee would experience any meaningful improvement in mobility from arterial intervention. The 
documentation does not meet the medically necessary requirements for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the in-office vascular surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve revascularization, endovascular, open or percutaneous, iliac artery, 
unilateral, initial vessel; with transluminal angioplasty (37220) revascularization, endovascular, open or 
percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty 
within the same vessel, when performed (37221) 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, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the 
same vessel, when performed (37229).