Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37233. We decided that the Plan does not have to pay for the services.  
 
You asked the Plan to pay for 37233. You say that this should be paid for. The Plan says that the denied codes 
remain not supported. 
 
We decided that the Plan has to pay for 37253 and 75710.  
 
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 for CPT 37233. Our reviewer says that this code is 
supported in the medical records. Our physician reviewer found that the operative report describes an initial 
tibial/peroneal artery treated, as well as, posterior artery. The guidelines say to use a single primary code 
(37228, 37229, 37230, 37231) for the initial tibial/peroneal artery treated in each leg. If other tibial/peroneal 
vessels are treated in the same leg, report these interventions using the appropriate add-on codes (37232-
37235). You may report up to two add-on codes in this territory, depending on whether two or all three 
tibial/peroneal vessels are treated. Use the add-on codes only for different vessels, not for distinct lesions in the 
same vessel. This procedure should be covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37233 have been met. Therefore, we decided that the Plan has to pay for 37253 
and 75710.  
 
We also decided that the Plan does not have to pay for the services. 
 
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 for CPT 37253 and 75710. Our reviewer says that 
these services are not supported in the medical records. Our physician reviewer found that in terms of CPT 
37253, the operative report does not include documentation of intravascular ultrasound during diagnostic 
evaluation and/or therapeutic intervention, each additional vessel. In terms of CPT 75710, the operative report 
does not include documentation of additional radiology procedure in addition to radiology services inclusive to 
CPT 37232, and therefore this procedure cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services. 
 
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.