Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an angiography (75710), ultrasound guidance for vascular access 
requiring ultrasound evaluation of potential access sites (76937), moderate sedation services, initial 15 minutes 
of intraservice time (99152), moderate sedation services, each additional 15 minutes intraservice time (99153), 
revascularization (37220, 37229), selective catheter placement, arterial system; each first order abdominal, 
pelvic, or lower extremity artery branch, within a vascular family (36245), selective catheter placement, arterial 
system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family 
(36246) and selective catheter placement, arterial system; initial third order or more selective abdominal, 
pelvic, or lower extremity artery branch, within a vascular family (36247). 
 
You asked the Plan to pre-approve an angiogram with revascularization. You say that the procedures are 
medically necessary for the enrollee. The Plan denied your request. The Plan says that the original 
determination was made based on no trial of conservative exercise therapy and there is no documentation of 
significant functional or lifestyle-altering impairment from pain despite maximally tolerated nonoperative 
therapy (e.g., medication, smoking cessation, exercise program). The requested revascularization is not 
medically necessary at this time. 
 
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 an angiogram with revascularization. 
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 treatments in 
question. The enrollee is status post left lower extremity arterial intervention on October 4, 2022, and 
subsequently, right lower extremity arterial intervention via a left groin approach on October 26, 2022. He 
presents relatively shortly thereafter with worsening of his ABIs and worsening of his symptoms reported now 
to have claudication at less than 50 feet with an ABI of 0.25 on the left. The deterioration may possibly 
represent a complication from either the recent left lower extremity intervention or from the access site (left 
groin) at the time of the right lower extremity intervention. As these findings suggest a worsening, potentially 
limb threatening, ischemia to his left lower extremity, angiography and possible intervention is medically 
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 an angiogram with revascularization have been met. Therefore, we decided that 
the Plan has to pre-approve an angiography (75710), ultrasound guidance for vascular access requiring 
ultrasound evaluation of potential access sites (76937), moderate sedation services, initial 15 minutes of 
intraservice time (99152), moderate sedation services, each additional 15 minutes intraservice time (99153), 
revascularization (37220, 37229), selective catheter placement, arterial system; each first order abdominal, 
pelvic, or lower extremity artery branch, within a vascular family (36245), selective catheter placement, arterial 
system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family 
(36246) and selective catheter placement, arterial system; initial third order or more selective abdominal, 
pelvic, or lower extremity artery branch, within a vascular family (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.