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), includes angioplasty within the 
same vessel, when performed (37230, 37229, 37228), 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, 37226, 37225, 37224), and revascularization, 
endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), 
includes angioplasty within the same vessel, when performed (37221, 37220). 
 You asked the Plan to pre-approve revascularization, endovascular, open or percutaneous, tibial, peroneal 
artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same 
vessel, when performed, 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, and revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial 
vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed.. 
You say that this is medically necessary. The Plan denied your request. The Plan says that the request is not 
medically necessary because the records show the enrollee does not have obstructive lesions on the leg arteries. 
The ankle-brachial index values are normal. The enrollee has leg pain, but the history is not necessarily 
consistent with claudication due to vascular insufficiency. 
 
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 revascularization, endovascular, open 
or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes 
angioplasty within the same vessel, when performed, 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, and revascularization, endovascular, open or 
percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty 
within the same vessel, when performed.. Our reviewer says that the service is not medically necessary. Our 
physician reviewer found there is documentation of poor pulses in the enrollee's lower legs bilaterally with 
discoloration of the left second toe and a painful non-healing spot on the right foot. There is also 
documentation of atherosclerotic lower extremity disease on duplex. While the ankle-brachial index values are 
normal, it is possible that they are artifactually elevated due to vessel wall calcification. As the documented 
findings could potentially represent limb threatening ischemia, a plan to perform angiography and possible 
intervention should be covered. It should be noted that the approval of the intervention codes in question are 
only provisional. It is not possible to predict what codes will be needed until after angiography is 
performed.  Final coverage would depend on angiographic findings and associated documentation. 
 
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, endovascular, open or percutaneous, tibial, peroneal artery, 
unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, 
when performed, 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, and revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; 
with transluminal stent placement(s), includes angioplasty within the same vessel, when performed. 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), includes 
angioplasty within the same vessel, when performed (37230, 37229, 37228), 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, 37226, 37225, 37224), and 
revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal 
stent placement(s), includes angioplasty within the same vessel, when performed (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.