Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T\transluminal balloon angioplasty (except lower 
extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or 
percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery; each additional artery (37247), revascularization, endovascular, open or 
percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, 
includes angioplasty within the same vessel, when performed (37227), and insertion or replacement of 
temporary transvenous dual chamber pacing electrodes (33211). 
 
You asked the Plan to pre-approve codes 37247, 37227 and 33211. You say that the records provided support 
the need for the services which remain in dispute. The Plan denied your request. The Plan says the services 
which remain in dispute are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 codes 37247, 37227 and 33211. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a planned kidney transplant, in the setting of a prior history 
of aortic valve stenosis, with planned transcatheter aortic valve replacement (TAVR). There is no 
documentation of significant lower extremity occlusive arterial disease. The recent cardiologist visit in October 
of 2023 indicates that the enrollee has no cardiac symptoms and is denying chest pain, palpitations, shortness of 
breath, or dyspnea. A stress echocardiogram was negative for ischemia and showed preserved left ventricular 
ejection fraction. He was felt to be NYHA functional Class I. There is no documentation of symptomatic 
bradycardia. In summary, there is insufficient documentation to support the medical necessity for lower 
extremity angiography and revascularization (37227); transluminal balloon angioplasty for occlusive disease, 
intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and 
radiological supervision and interpretation necessary to perform the angioplasty within the same artery, each 
additional artery (37247); or placement of a temporary pacemaker (33211).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 37247, 37227 and 33211 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve T\transluminal balloon angioplasty (except lower extremity artery(ies) 
for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all 
imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same 
artery; each additional artery (37247), revascularization, endovascular, open or percutaneous, femoral, popliteal 
artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the 
same vessel, when performed (37227), and insertion or replacement of temporary transvenous dual chamber 
pacing electrodes (33211).