Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for transluminal balloon angioplasty and interpretation necessary to perform the angioplasty within the same vein; initial vein or transluminal balloon angioplasty provided on September 14, 2020
You asked the Plan to pay for transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; initial vein (37248) and transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; each additional vein (List separately in addition to code for primary procedure) (37249). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the operative report did not include documentation of a transluminal balloon angioplasty nor of an open or percutaneous transluminal balloon angioplasty.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 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 pay for transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; initial vein (37248) and transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; each additional vein (List separately in addition to code for primary procedure) (37249). Our reviewer says that the documentation does not support the use of additional codes coding for venous angioplasty of a single vein followed by an additional venous angioplasty of a different vein. Our physician reviewer found the patient underwent posterior tibial artery atherectomy and angioplasty and attempted AV fistula creation. These were covered with approved codes 37229 (tibial atherectomy with PTA) and 37799 (unlisted vascular procedure). The documentation does not indicate additional work that would justify 2 additional venous angioplasty codes. Agree with health plan determination. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; initial vein (37248) and transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; each additional vein (List separately in addition to code for primary procedure) (37249) have not been met. Therefore, we decided that the Plan does not have to pay for transluminal balloon angioplasty and interpretation necessary to perform the angioplasty within the same vein; initial vein or transluminal balloon angioplasty provided on September 14, 2020.