Heart and vein procedures: 62% of denials overturned

Year by year

By treatment

Treatments with at least 20 decisions, most decisions first. Rates on fewer than 20 decisions aren’t shown.

Recent decisions

The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.

1. Overturned 2025 · Medical necessity · age 51–64 Vein procedures · Heart and circulation The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for splenic artery embolization (SAE). Partial splenic embolization is a well-established, organ-preserving, minimally invasive…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for splenic artery embolization (SAE). Partial splenic embolization is a well-established, organ-preserving, minimally invasive therapy used to reduce spleen size and splenic parenchymal blood flow. It is widely accepted in modern interventional radiology practice for clinical scenarios where splenic size or fragility poses a risk for hypersplenism, cytopenias, or traumatic/atraumatic rupture. In this case, the patient has longstanding idiopathic splenomegaly, documented prior splenic rupture, and ongoing clinically significant risk of re-rupture. Extensive hematologic, hepatic, autoimmune, and oncologic evaluations have ruled out reversible or treatable causes. Therefore, observation alone does not mitigate the patient’s known rupture risk, and splenectomy would remove the entire reticuloendothelial organ and confer lifelong infectious risk. Partial splenic embolization provides an organ-preserving alternative with durable reduction in splenic volume and capsular pressure, thereby lowering rupture risk while maintaining immune function. Published studies demonstrate that partial splenic embolization reduces splenic size, preserves immunologic tissue, and is effective and safe when performed electively in high-risk splenomegaly patients. Given the patient’s history of documented prior rupture, persistent massive splenomegaly, and ongoing high rupture risk, partial splenic embolization is indicated for this patient. Deferring the procedure would place the patient at foreseeable risk of repeat hemorrhage. For these reasons, the requested SAE is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedure is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in interventional radiology and diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-45977

2. Upheld 2025 · Medical necessity · age 51–64 Heart surgery · Heart and circulation The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for an endovascular revascularization of an initial, unilateral iliac artery, which includes transluminal stent placement and…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for an endovascular revascularization of an initial, unilateral iliac artery, which includes transluminal stent placement and angioplasty procedure. The provided documentation does not support the medical necessity of the requested procedure. There is a lack of clarity as to the etiology of the patient’s leg symptoms, and alternative etiologies do not appear to have been considered, including a possible neurogenic or musculoskeletal etiology. The last documented plan was for a conservative approach. Given these findings, the requested endovascular revascularization of an initial, unilateral iliac artery, which includes transluminal stent placement and angioplasty procedure, is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedure is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in general surgery with subspecialty certification in vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-45919

3. Overturned 2025 · Medical necessity · age 51–64 Heart surgery · Heart and circulation The physician reviewer found that a patient has requested authorization and coverage for endovascular revascularization with atherectomy, including angioplasty, of both lower extremities.The current medical literature and the records provided support the…

   The physician reviewer found that a patient has requested authorization and coverage for endovascular revascularization with atherectomy, including angioplasty, of both lower extremities.The current medical literature and the records provided support the requested endovascular revascularization with atherectomy, including angioplasty, of both lower extremities as medically necessary for the treatment of this patient. Clinical documentation reflects symptoms and objective findings consistent with significant peripheral arterial disease requiring further intervention. One study noted that patients with peripheral artery disease “often have reduced walking capacity and are at risk of acute and chronic critical limb ischemia leading to major adverse limb events, such as peripheral revascularization or amputation.” Applying the guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA), the requested endovascular revascularization with atherectomy, including angioplasty, of both lower extremities is indicated to further assess and manage this patient’s condition. Therefore, the requested endovascular revascularization with atherectomy, including angioplasty, of both lower extremities is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in general surgery with subspecialty certification in vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-45435

4. Upheld 2025 · Medical necessity · age 51–64 Other · Heart and circulation The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a transcatheter ablation procedure. Current guidelines recommend atrial fibrillation ablation in symptomatic patients with paroxysmal or…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a transcatheter ablation procedure. Current guidelines recommend atrial fibrillation ablation in symptomatic patients with paroxysmal or persistent atrial fibrillation who are refractory or intolerant to at least one antiarrhythmic medication. In this case, given that the submitted records did not indicate that the patient had tried and failed, or been unable to tolerate, at least one antiarrhythmic medication at the time the service at issue was performed, a transcatheter ablation procedure was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service at issue was not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-45323

5. Overturned 2025 · Medical necessity · age 41–50 Vein procedures · Heart and circulation The physician reviewer found that a patient has requested authorization and coverage for endovenous ablation therapy of incompetent vein, injection of sclerosant, and stab phlebectomy of varicose veins to the right leg. In this case, the patient meets the…

   The physician reviewer found that a patient has requested authorization and coverage for endovenous ablation therapy of incompetent vein, injection of sclerosant, and stab phlebectomy of varicose veins to the right leg. In this case, the patient meets the criteria for the medical appropriateness of the procedures requested. The patient has a recurrence of venous insufficiency from procedures performed previously. The patient has new varicose veins that have not resolved within a timeframe while practicing conservative measures which impact his quality of life. The patient‘s repeat duplex ultrasound of the right lower extremity demonstrates no deep vein thrombosis (DVT), and the patient’s small saphenous vein (SSV) had reflux with a size greater than 3mm in diameter. Based upon the physical examination and the duplex ultrasound, the patient meets criteria for recurrent symptomatic varicose veins that failed conservative measures with reflux time greater than 500msec in the targeted segment. It is well documented and established that requested concurrent combined therapy is the most advantageous and most efficient treatment modality for recurrent and refractory varicose veins. As such, the requested endovenous ablation therapy of incompetent vein, injection of sclerosant, and stab phlebectomy of varicose veins to the right leg, are medically necessary for the treatment of the patient. Final Result: The reviewer determined that the services are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-45110

6. Upheld 2025 · Medical necessity · age 41–50 Other · Heart and circulation The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for ultrasound guided foam sclerotherapy (Varithena) of the right calf tributaries. In this case, the documentation notes the…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for ultrasound guided foam sclerotherapy (Varithena) of the right calf tributaries. In this case, the documentation notes the patient is feeling much better, has some discomfort, has no edema, and has no significant symptoms. There is a lack of support in the literature for the use of sclerotherapy in treating patients without significant symptoms and edema. Additionally, the code requested is not consistent with the treatment plan. While the treatment plan calls for tributary treatment, the code in question is not the code for tributary treatment, but rather a code for truncal treatment. All told, the requested ultrasound guided foam sclerotherapy (Varithena) of the right calf tributaries is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedure is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in general surgery with subspecialty certification in vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-45079

7. Upheld 2025 · Medical necessity · age 51–64 Other · Heart and circulation The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for left heart catheterization with coronary angiography and percutaneous coronary intervention, including stent placement. Based on the records…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for left heart catheterization with coronary angiography and percutaneous coronary intervention, including stent placement. Based on the records provided, the patient had increased cardiovascular risk and atypical chest pain but no evidence of ischemia on appropriate stress testing. In this clinical setting, coronary angiography is not indicated. Additionally, findings are consistent with diffuse coronary disease, which is typically managed with medical therapy rather than stent placement. Overall, the documentation does not support an indication for invasive coronary evaluation or intervention. Therefore, the requested procedures were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the procedures at issue were not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-44962

8. Overturned 2025 · Medical necessity · age 51–64 Other · Heart and circulation Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a coronary angiogram, including placement of catheter(s) and stent(s). This patient has several traditional Framingham risk factors for obstructive coronary…

   Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a coronary angiogram, including placement of catheter(s) and stent(s). This patient has several traditional Framingham risk factors for obstructive coronary artery disease (CAD), including hypertension and hyperlipidemia. Other risk enhancers are also present, including elevated lipoprotein(a) (Lp(a)) and a markedly elevated coronary artery calcium (CAC) score. With this patient’s gender, age, nature of symptoms (dyspnea), and elevated CAC score in mind, the patient’s probability of obstructive CAD is significant. The presence of suspicious dyspnea-equivalent anginal symptoms coupled with abnormal stress testing only heightens this risk. A recent analysis in symptomatic patients undergoing serial CAC score measurement showed that a significant number of patients with a higher CAC score at baseline showed progressive increase in atherosclerotic plaque burden, often suggesting advanced atherosclerotic disease. Several similar studies have reported on the significance of progressive increase in CAC through serial imaging, predicting coronary plaque presence and progression. Overall, treatment guidelines and appropriate use criteria strongly support the use of diagnostic coronary angiography, including placement of catheter(s) and stent(s), for this symptomatic patient with high-risk findings. All told, the requested coronary angiogram, including placement of catheter(s) and stent(s), is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested procedure is medically necessary for the evaluation of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in internal medicine with subspecialty certifications in cardiovascular disease and clinical cardiac electrophysiology and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-44850

9. Overturned 2025 · Medical necessity · age 65+ Other · Heart and circulation Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Computed Tomography Fractional Flow Reserve (CT-FFR) analysis and stent placement. In this case, the patient has known severe coronary disease with stable angina…

   Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Computed Tomography Fractional Flow Reserve (CT-FFR) analysis and stent placement. In this case, the patient has known severe coronary disease with stable angina as well as provokable ischemia on stress testing in the inferior and anterolateral left ventricular (LV) wall segments. In this circumstance, the territories of ischemia are already known based on the stress test results and indicate that stenoses in these areas are functionally significant. Clinical information obtained from a CT-FFR would be duplicative and would not provide any additional information for the management of the patient. Thus, the requested CT-FFR analysis is not medically necessary for the evaluation of the patient’s severe coronary disease. However, the records provided for review reveal that the patient has limiting chest pain with provokable ischemia on stress testing and severe coronary stenosis. The revascularization of the patient’s arteries with stenting is reasonable and appropriate in this clinical setting. As such, the requested stent placement is medically necessary for the treatment of the patient’s severe coronary disease Final Result: The reviewer determined that a portion of the requested services is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be partially overturned. Credentials/Qualifications: The reviewer is board-certified in internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-44583

10. Upheld 2025 · Medical necessity · age 65+ Other · Heart and circulation Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for left heart catheterization with possible percutaneous coronary intervention (PCI). Based on the records, this patient presents with coronary artery disease but…

    Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for left heart catheterization with possible percutaneous coronary intervention (PCI). Based on the records, this patient presents with coronary artery disease but has no angina while active and has silent mild-to-moderate lateral wall ischemia on nuclear stress testing. In this setting of a stable asymptomatic patient with silent ischemia in a single vessel distribution, treatment with coronary revascularization, including PCI, has not been shown to improve outcome compared to medical therapy alone. Additionally, the current guidelines do not recommend coronary angiography in this patient’s clinical setting. Overall, based on the medical records, coronary angiogram and revascularization are not supported for this patient. For these reasons, the requested left heart catheterization with possible PCI is not medically necessary for the patient. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-44529

11. Upheld 2025 · Medical necessity · age 51–64 Other · Heart and circulation Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for cardiac monitoring device replacement. Findings: The physician reviewer found that Implantable loop recorders are usually used for rare events that may be…

    Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for cardiac monitoring device replacement. Findings: The physician reviewer found that Implantable loop recorders are usually used for rare events that may be caused by an arrhythmia but that have not been able to be captured on external monitoring devices. Current guidelines for the management of atrial fibrillation do not recommend the routine use of implantable loop recorders after ablation. In this case, there is a lack of extenuating circumstances, such as arrhythmic events undetectable by external monitoring, in the record to support the use of an implantable loop recorder as an exception. All told, the requested cardiac monitoring device replacement is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested procedure is not medically necessary for the evaluation of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-44142

12. Overturned 2025 · Medical necessity · age 41–50 Pacemaker/Defib · Heart and circulation Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for pacemaker implantation. Painful left bundle branch block syndrome results from mechanical dyssynchrony in the absence of myocardial ischemia. Although formal…

    Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for pacemaker implantation. Painful left bundle branch block syndrome results from mechanical dyssynchrony in the absence of myocardial ischemia. Although formal guidelines, consensus statements, and randomized controlled trials are limited, the requested pacemaker implantation is appropriate for this patient based on case reports. The request for permanent His bundle pacing is an effective treatment strategy owing to the restoration of normal cardiac physiology. One study commented that “Treatment options include the use of beta-blockers to reduce heart rate and cardiac pacing therapy aimed at reestablishing normal ventricular activation, through biventricular or His bundle pacing (HBP).” Another study noted in the two patients assessed, left bundle branch area pacing “resulted in resolution of the left bundle branch block and associated symptoms.” This patient has attempted treatment with maximally tolerated medications, including nitrates, beta-blockers, calcium channel blockers, and Ranexa but remained symptomatic. Therefore, the requested pacemaker implantation is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in cardiovascular disease with subspecialty certification in interventional cardiology and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-43644