Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve 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 (CPT code 37231) and selective catheter placement, 
arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within 
a vascular family (CPT code 36247). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that your request is not medically necessary because your records show you do not have 
documentation that opening this blood vessel will improve the current symptoms of claudication and exactly 
what are the symptoms you are experiencing with this detected stenosis in the leg vessel. 
 
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 the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation supports the medical necessity of the treatment in question. There is 
documentation that you are having lifestyle limiting claudication that did not satisfactorily improve with 
conservative efforts including an exercise regimen. You have recently undergone angiography that 
demonstrated bilateral lower extremity arterial occlusive disease and is status post endovascular intervention on 
the right with subsequent improvement in claudication. There is now a request to treat the left side. As you 
have documented bilateral lower extremity claudication as well as documented bilateral arterial occlusive 
disease and experienced improvement on the right following intervention, it would be reasonable and medically 
necessary to proceed with similar intervention on the left.  If the left is not intervened upon, the procedure on 
the right would have effectively been a waste of time and risk. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve 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 (CPT code 37231) and selective catheter placement, arterial system; initial third order or more 
selective abdominal, pelvic, or lower extremity artery branch, within a vascular family (CPT code 36247).  
 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.