Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve selective catheter placement and revascularization for the 
tibial/peroneal, femoral/popliteal and iliac arteries (36247, 36246, 37229, 37228, 37227, 37226, 37225, 37224, 
37221, 37220). 
 
You asked the Plan to pre-approve selective catheter placement and revascularization for the tibial/peroneal, 
femoral/popliteal and iliac arteries. You say that this is medically necessary. The Plan denied your request. The 
Plan says that this is not medically necessary. Records show the enrollee does not have obstructive lesions on 
the leg arteries, and that the enrollee does not have an "occlusive process." The enrollee's arterial duplex from 
February 2023, shows no occlusive disease. The enrollee has a right leg ulcer documented in multiple notes as 
due to venous stasis. 
 
The Plan follows Medicare rules. 
 
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 selective catheter placement and 
revascularization for the tibial/peroneal, femoral/popliteal and iliac arteries. Our reviewer says that the service 
is not medically necessary. Our physician reviewer found despite the limited documentation, there is enough 
evidence that the enrollee may have limb threatening ischemia to the right lower extremity and therefore the 
procedures in question are medically necessary and coverage criteria met. There is documentation of a 
nonhealing right lower extremity ulcer and a recent ankle-brachial index (ABI) documented to be 0.78 on the 
right which represents a deterioration from the ABI and duplex study from February.  As the patient is diabetic, 
ABIs may be artificially elevated in both instances. There is also evidence in the medical record of peripheral 
arterial disease (PAD) including a history of intervention performed on the arteries of the right leg in the past as 
well as some clinical features including absence of hair on the lower leg. It is possible approval for this 
procedure may have been available sooner if the surgeons notes were provided.  However, as noted above, would not delay coverage in order to obtain this as there is sufficient documentation 
from the wound center to support the medical necessity and reasonableness of diagnostic angiography and 
possible intervention.  It should be noted that the interventional codes are preliminary and that these would 
only be covered if the diagnostic angiogram demonstrated appropriate lesions for treatment. However, it is not 
possible to predict which intervention codes will be needed until the time of the actual angiogram. In summary, 
recommend coverage of the procedures in question recognizing that the intervention codes are conditional. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of selective catheter placement and revascularization for the tibial/peroneal, 
femoral/popliteal and iliac arteries have been met. Therefore, we decided that the Plan has to pre-approve 
selective catheter placement and revascularization for the tibial/peroneal, femoral/popliteal and iliac arteries 
(36247, 36246, 37229, 37228, 37227, 37226, 37225, 37224, 37221, 37220).  
 
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.