Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve revascularization, endovascular, open or percutaneous, femoral, 
popliteal artery(s) (37225), secondary percutaneous transluminal thrombectomy (37186), revascularization, 
endovascular, open or percutaneous, tibial, peroneal artery (37231), and 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). 
 
You asked the Plan to pre-approve revascularization, endovascular, open or percutaneous, femoral, popliteal 
artery(s), secondary percutaneous transluminal thrombectomy, revascularization, endovascular, open or 
percutaneous, tibial, peroneal artery, and revascularization, endovascular, open or percutaneous, femoral, 
popliteal artery(s), unilateral. You say that the services are necessary. The Plan denied your request. The Plan 
says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that vascular stents are used to enhance primary patency 
in arteries and veins, usually at the site of stenotic or occlusive lesions.  Stents also may be used as an adjunct to technically inadequate Percutaneous Transluminal Angioplasty (PTA) or in cases where PTA alone will not be expected to provide a durable result. 
 
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, femoral, popliteal artery(s), secondary percutaneous transluminal thrombectomy,
revascularization, endovascular, open or percutaneous, tibial, peroneal artery, and revascularization,
endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral. Our reviewer says that the services
are medically necessary. Our physician reviewer found the documentation supports the medical necessity of the
procedure in question. The enrollee has undergone bilateral lower extremity revascularization, fairly recently
on the right side. The enrollee presents with lifestyle limiting claudication due to occlusion of the right
superficial femoral artery. Without proceeding with this currently requested procedure, the enrollee's previous
efforts would have been for nothing as he is unable to enjoy the improvement in the left leg due to the short
distance claudication on the right. It appears that the occlusion is isolated to the superficial femoral artery and
does not include the tibial arteries. Treatment of superficial femoral artery occlusive disease for lifestyle
limiting claudication is an accepted indication, is reasonable, and, in this case, 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 revascularization, endovascular, open or percutaneous, femoral, popliteal 
artery(s), secondary percutaneous transluminal thrombectomy, revascularization, endovascular, open or 
percutaneous, tibial, peroneal artery, and revascularization, endovascular, open or percutaneous, femoral, 
popliteal artery(s), unilateral have been met. Therefore, we decided that the Plan has to pre-approve 
revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s) (37225), secondary 
percutaneous transluminal thrombectomy (37186), revascularization, endovascular, open or percutaneous, 
tibial, peroneal artery (37231), and 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).  
 
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.