Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a selective catheter placement (first-order), main renal artery and 
any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), 
fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological 
supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram 
when performed; unilateral (36251) and a computed tomography guidance for needle placement (e.g., biopsy, 
aspiration, injection, localization device), radiological supervision and interpretation (77012). 
 
You asked the Plan to pre-approve a renal ablation, angiogram, and biopsy. You say that the requested 
procedures are medically necessary. The Plan denied your request. The Plan says that the services requested do 
not meet medical necessity. There is no documentation that this is clinical stage I renal lesion. There is no 
documentation that the enrollee is not a candidate for oral lacks against active surveillance or surgery. There is 
no documentation that the lesion is not an angiomyolipoma. 
 
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 a renal ablation, angiogram, and biopsy. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a slowly growing right renal tumor which is solid. The 
renal angiogram for ablation, CPT 36251 is necessary for the ablation procedure and the CT guidance for 
biopsy of the mass, CPT 77012 is also necessary since tissue diagnosis will be necessary. The above 
procedures are safer and less invasive than partial nephrectomy. The slowly growing nature of the mass 
necessitates tissue sampling which will be mapped out using the CT guidance. These procedures are 
compatible with the LCD guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a renal ablation, angiogram and biopsy have been met. Therefore, we decided 
that the Plan has to pre-approve a selective catheter placement (first-order), main renal artery and any accessory 
renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, 
contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and 
interpretation, including pressure gradient measurements when performed, and flush aortogram when 
performed; unilateral (36251) and a computed tomography guidance for needle placement (e.g., biopsy, 
aspiration, injection, localization device), radiological supervision and interpretation (77012).  
 
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.