Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovascular repair of infrarenal aorta and/or iliac 
artery(ies) by deployment of an aorto-bi-iliac endograft including pre-procedure sizing and device selection, all 
nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft 
extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all 
angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for other than rupture 
(eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer) (34705) and inpatient hospital care. 
 
You asked the Plan to pre-approve the services. You say that an aneurysm can burst and cause severe medical 
complications and or even death. The Plan denied your request. The Plan says the enrollee's records do not 
show that the enrollee's aneurysm is ruptured or symptomatic. The Plan states the records do not show that the 
enrollee's aneurysm is greater than 5.5 centimeters. The Plan states it has not expanded by more than 10 
millimeters in a year, or 5 millimeters in 6 months.  
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the reviewed documentation indicates that the records do not show that the enrollee's aneurysm 
is ruptured or symptomatic. They do not show that the aneurysm is greater than 5.5 centimeters. It has not 
expanded by more than 10 millimeters in a year, or 5 millimeters in 6 months.  Endovascular repair of 
infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac endograft including pre-procedure 
sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and 
interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the iliac 
bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; 
for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer) (34705) in this case is 
not medically reasonable or necessary. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-
bi-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all 
associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the 
level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the 
renal arteries to the iliac bifurcation; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, 
penetrating ulcer) (34705) and inpatient hospital care.