Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve revascularization, restoring blood flow in an area of the body by 
unblocking blood vessels with one of several methods, includes placement of a balloon that inflates to allow 
blood flow and a laser that cleans out the blood vessels (37227). 
 
You asked the Plan to pre-approve revascularization, restoring blood flow in an area of the body by unblocking 
blood vessels with one of several methods, includes placement of a balloon that inflates to allow blood flow 
and a laser that cleans out the blood vessels. You say that this is medically necessary. The Plan denied your 
request. The Plan says that medical necessity of the lower extremity revascularization procedure is not met 
because the submitted vascular study provided does not document severe stenosis to the left lower extremity. 
There is no documentation of lifestyle limiting claudication. The enrollee is noted to be asymptomatic. There is 
no documentation of ischemic rest pain and non-healing ulcers, consistent with limb threatening ischemia. 
 
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 revascularization, restoring blood flow 
in an area of the body by unblocking blood vessels with one of several methods, includes placement of a 
balloon that inflates to allow blood flow and a laser that cleans out the blood vessels. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the patient has a history of a femoral to tibial-peroneal trunk bypass with vein. At a recent 
surveillance, the patient was identified to have an area of elevated velocities (suggesting possible stenosis) in 
the graft and was therefore closely followed. At the subsequent follow-up (his most recent follow-up), the toe 
pressures were considerably decreased in comparison to the previous, and the bypass was difficult to 
visualize. While elevated velocities were not noted on this most recent study, areas of stenosis typically do not 
disappear and the findings may represent worsening of the stenosis and possible graft threat. In this situation, 
getting an angiogram and intervening on any graft threatening stenosis is both reasonable and medically 
necessary. In this case, the absence of symptoms does not impact the decision making as the indication for 
intervention is graft preservation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization, restoring blood flow in an area of the body by unblocking 
blood vessels with one of several methods, includes placement of a balloon that inflates to allow blood flow 
and a laser that cleans out the blood vessels have been met. Therefore, we decided that the Plan has to pre-
approve revascularization, restoring blood flow in an area of the body by unblocking blood vessels with one of 
several methods, includes placement of a balloon that inflates to allow blood flow and a laser that cleans out 
the blood vessels (37227).  
 
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.