Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcatheter therapy, arterial infusion for thrombolysis other 
than coronary or intracranial, any method, including radiological supervision and interpretation, initial 
treatment day (CPT Code 37211) and primary percutaneous transluminal mechanical thrombectomy, 
noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance and 
intraprocedural pharmacological thrombolytic injection(s); second and all subsequent vessel(s) within the same 
vascular family (CPT Code 37185) provided on February 13, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. 
 
Procedure code 37211-59-LT is not supported by the medical records submitted. The operative report did not 
include documentation of a transcatheter therapy, arterial infusion for thrombolysis other than coronary or 
intracranial, any method, including radiological supervision and interpretation, initial treatment day; therefore 
this code cannot be verified.After careful review of the operative report, the Medical Director states; ?the 
requested service code is not substantiated by the clinical documentation in the medical records submitted for 
review. Per NCCI Chapter V-A (Introduction): Physicians should report the HCPCS/CPT code that describes 
the procedure performed to the greatest specificity possible. A HCPCS/CPT code should be reported only if all 
services described by the code are performed. In this case, in the narrative of the operative report, the requested 
CPT code was not documented. As a result, the requested procedure code is not substantiated by the clinical 
documentation in the operative report submitted for review. Therefore, CPT code 37211-59-LT cannot be 
verified. ?To cite the operative report; ?A repeat left lower extremity arteriogram was performed through the 
quick cross catheter. Next access was obtained down the peroneal artery using a combination of the quick cross 
catheter and the V18 guidewire 2mg of altplase was injected into the peroneal artery. Subsequent catheter 
embolectomy/thrombectomy was performed using a 4 French VER catheter. ?Per the National Correct Coding 
Initiative Policy Manual for Medicare Services, Revision Date: 1/1/2020; in regards to the submitted (CPT) 
code of 37211-59-LT, Transcatheter thrombolysis infusion is most commonly used to treat symptomatic 
inferior vena cava thrombosis that is responding poorly to the routine anticoagulation regimen or symptomatic 
iliofemoral or femoropopliteal deep vein thrombosis (DVT) in patients with a low risk of bleeding. A 
diagnostic arteriography or venography is performed to pinpoint the extent of the thrombosis. The physician 
places a needle into the blood vessel. A guidewire is threaded through the needle to the site of the clot using 
fluoroscopic guidance and the needle is removed. An infusion catheter is threaded to the site and the wire is 
extracted. A thrombolytic pharmaceutical is administered directly to the thrombosis. During the infusion, the 
patient is on bed rest with frequent monitoring. Once the thrombosis has dissipated satisfactorily, the infusion 
is stopped and the catheter removed. Pressure is applied over the puncture site to stop the bleeding. Report 
37211 for the first day of arterial transcatheter therapy; 37212 for the first day of venous transcatheter therapy; 
37213 for each subsequent day of arterial or venous therapy, including follow-up catheter contrast injection, 
position change, or exchange, if applicable; and 37214 for the last day the thrombolysis is administered, 
including removal of the catheter and closure of the access site. These codes are not for use when thrombolysis 
is performed on coronary or intracranial arteries. When medically necessary, report moderate (conscious) 
sedation provided by the performing physician with 99151-99153. When provided by another physician, report 
99155-99157. Codes 37211?37214 are resequenced codes and will not display in numeric order. These are 
unilateral procedures. If performed bilaterally, some payers require that the service be reported twice with 
modifier 50 appended to the second code while others require identification of the service only once with 
modifier 50 appended. Check with individual payers. Modifier 50 identifies a procedure performed identically 
on the opposite side of the body (mirror image). Catheter placement, diagnostic studies, and any other 
percutaneous interventions performed are separately reportable. Fluoroscopic guidance and radiological 
supervision and interpretation are included in 37211?37214. These codes should only be reported once per 
treatment day. For ultrasound guidance for vascular access, see 76937. For declotting of an implanted vascular 
access device or catheter by thrombolytic agent, see 36593. For mechanical thrombectomy and/or thrombolysis 
infusion performed on an intracranial artery, see 61645.This description was not documented in the operate 
report narrative. According to (CPT) code definitions and guidance, this case involves an inappropriate billing 
of (CPT) code 37211-59-LT. (CPT) code 37211-59-LT is not supported in the documentation therefore is not 
payable. 
 
Procedure code 37185-59 is not supported by the medical records submitted. The operative report did not 
include documentation of a primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-
intracranial, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural 
pharmacological thrombolytic injection(s); second and all subsequent vessel(s) within the same vascular family 
(Listed separately in addition to code for primary mechanical thrombectomy procedure); therefore, this code 
cannot be verified. After careful review of the operative report, the Medical Director states; ?the requested 
service code is not substantiated by the clinical documentation in the medical records submitted for review. Per 
NCCI Chapter V-A (Introduction): Physicians should report the HCPCS/CPT code that describes the procedure 
performed to the greatest specificity possible. A HCPCS/CPT code should be reported only if all services 
described by the code are performed. In this case, in the narrative of the operative report, the requested CPT 
code was not documented. As a result, the requested procedure code is not substantiated by the clinical 
documentation in the operative report submitted for review. Therefore, CPT code 37185-59cannot be verified. 
?To cite the operative report; - Unable to cite. The requested procedure was not documented in the medical 
records submitted for review. Per the National Correct Coding Initiative Policy Manual for Medicare Services, 
Revision Date: 1/1/2020; in regards to the submitted (CPT) code of 37185-59, the physician treats an acute 
noncoronary, nonintracranial arterial occlusion with a combination of thrombolytic drugs and percutaneous 
mechanical thrombectomy. The devices used for mechanical thrombectomy include those that fragment the 
thrombus with or without removal of the clot, as well as those that come into contact with the wall of the 
vessel. For the procedure using the Trellis device, the artery is cannulated to gain access and 5,000 units of 
heparin are administered. Angiography is performed to confirm the occluded arteries. A hydrophilic wire is 
passed across the occlusion, followed by passing of the Trellis device over a stiff exchange length wire. The 
distal and proximal balloons are inflated in the artery on either side of a treatment zone containing infusion to 
isolate the treatment zone and to sustain the fluid concentration that is infused. One milligram of tissue 
plasminogen activator (TPA) is infused into the treatment zone.  
 
The Trellis device is run at 4,000 rpm for five minutes. After the proximal balloon is deflated, small clots are 
removed via the integral aspiration port to prevent embolization. Fluoroscopic guidance services and injections 
administered during the course of the procedure are included in the service. Separately reportable procedures 
include other percutaneous interventions such as stent placement and diagnostic studies. Report 37184 for the 
first vessel and 37185 for the second and subsequent vessels in the same vascular family. Do not report 37184 
with 61645, 76000 or 96374. Do not report 37185 with 76000 or 96375. Do not report 37185 with 61645 when 
treating the same vascular territory. Codes 37184 and 37185 should not be used to report mechanical 
thrombectomy performed to remove short segments of thrombus or embolus discovered during other 
percutaneous interventional procedures, see 37186.This description was not documented in the operate report 
narrative. According to (CPT) code definitions and guidance, this case involves an inappropriate billing of 
(CPT) code 37185-59. (CPT) code 37185-59 is not supported in the documentation therefore is not payable. 
Therefore, we decided that the Plan does not have to pay for transcatheter therapy, arterial infusion for 
thrombolysis other than coronary or intracranial, any method, including radiological supervision and 
interpretation, initial treatment day (CPT Code 37211) and primary percutaneous transluminal mechanical 
thrombectomy, noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance 
and intraprocedural pharmacological thrombolytic injection(s); second and all subsequent vessel(s) within the 
same vascular family (CPT Code 37185) provided on February 13, 2020.