Enjoy! 

https://sites.google.com/site/abigailsarticles/august-2025-articles

Clotted forearm graft with compression at the venous side of graft when examined with sono, patient had marked  venous stenosis and hx of profuse bleeding from cannulation sites prior to clotting.  What are your thoughts?

We have had several denials from Blue Cross Blue Shield (BCBS) for WaveLinQ pAVF creation code 36837. Their denial reason is "code is not covered as procedure is considered investigational. The members policy does not cover investigational services".

We have appealed all of the denials with extensive comments/resources/literature (including it being an official CPT code, Medicare/Medicaid covering it, etc) but they have upheld their denial every time.

Anyone else having similar issues? How else can we handle such denials?

Hi Everyone: 

  I am working both general OP and Inpt Nephrology and doing Procedures in the hospital.  I've seen that the Vascular Surgeons do a Consult on the patients they get asked to do procedures and obviously do a separate procedure note. This is an opportunity to bill for 2 services and it actually is useful so one gets to know the patients and anticipate particular issues and avoid complications, i.e. having had a device in the past on either neck, sensitivities to moderate sedation , review labs etc 

  However If they place a consult for me - not my own patient I'm rounding on - I don't think there can be 2 nephrology inpatient consults, and I wouldn't think that we can do a consult as Vascular Surgery as we are Not.  so the Question: 

  a) Is there a code for Interventional Nephrology inpatient or for that matter outpatient consultations ? 

  b) Is there anyone else facing this issue and how are you addressing it ? 

Thanks 

Fernando 

I do fewer wrist fistulas because the arteries are smaller, the veins more likely to have been damaged by venipuncture and IVs, and the failure rates are higher. There is no reason to do a "pro forma" wrist fistula in dubious circumstances just to check an algorithmic box, and especially when the patient already has a catheter ticking or needs imminent dialysis, but there are some advantages to a more distal fistula, including a longer cannulation zone.

Sometimes this happens naturally - as in cases where the cephalic vein does not connect with the basilic system via the median ante/cubital bridge (maybe 10% of patients), but frequently the upper arm cephalic vein diminishes in size, flow and apparent usefulness with diversion of flow at the antecubital fossa (into the deep system via the perforating branches, and the basilic system via the median cubital - "MAC"), then via the first lateral branch above the antecubital fossa, where it drains to the veins of the profunda brachii. Above the first third of the arm it is also frequently deep.

To make the upper arm cephalic vein extension of a forearm fistula more usable, I frequently do an "antecubital disconnection" via a small incision just media to the cephalic, and over the first part of the median antecubital. After test clamping the MAC to make sure the fistula maintains its thrill, the MAC is doubly ligated and divided to expose the deep branch, which is then also skeletonized, doubly ligated and divided, making the cephalic the main outflow conduit and completing the disconnection. I generally skeletonize the cephalic thoroughly, as there may be several smaller deep branches in the area. This maneuver can be completed the same time at the wrist fistula, adding 20-30 minutes to the case.

A more ambitious modification is superficialization of the cephalic vein in the upper arm, not generally done at the same time as the wrist fistula, but always including the antecubital disconnection. If a robust median antecubital is left in place to drain the forearm to the low resistance basilic, the traumatized higher resistance cephalic vein may sclerose down and fail to develop, leaving you with nothing for your pains and promises.