Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 37228. We decided that the Plan does not have to pay 
for procedure codes 99199, 75710 and 37184.  
 
You asked the Plan to pay for procedure codes 37228, 99199, 75710 and 37184 billed for date of service 
February 3, 2022. You say that these services were reported correctly and are supported in the medical record. 
The Plan says that codes 37228 and 99199 are not supported in the medical record, and the payment for codes 
75710 and 37184 is included in the payment for other codes billed for this date. 
 
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 decided that the Plan has to pay for procedure code 37228.  
 
In this case, the CPT Code Manual definition of code 37228 is revascularization, endovascular, open or 
percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty. 
 
We asked our coder 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 procedure code 37228. Our reviewer says that code 37228 is 
supported in the medical record. Our coder found that the operative report describes a balloon angioplasty 
tibioperoneal trunk. The operative report documents, at this time the decision was made to balloon angioplasty 
the tibioperoneal trunk with a 3mm x 40mm balloon and followed by a 5mm balloon due to residual stenosis. 
In this case, the report supports that this procedure was performed. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 37228 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 37228.  
 
We also decided that the Plan does not have to pay for procedure codes 99199, 75710 and 37184. 
 
In this case, the CPT Code Manual definition of code 99199 is unlisted special service, procedure or report. We 
have also confirmed that code 37184 is a column II code to column I code 34203; however, 37184 was billed 
with a modifier. 
 
In addition, we have confirmed that code 75710 is a column II code to column I codes 34203 and 37184. These 
code pairs have a modifier indicator of 1; however, code 75710 has not been billed with an appropriate 
modifier to bypass the edits. Based on the claim submitted, Medicare billing criteria have not been met for code 
75710. 
 
We asked our coder 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 procedure codes 99199 and 37184. Our reviewer says that 
these codes are not supported for payment based on the records provided. Our coder found that the operative 
report does not include documentation of an unlisted special service, procedure or report. The report cannot be 
cited as this procedure was not found in the documentation. In addition, the operative report shows that the 
intervention reported by code 37184 was performed through the same access site, which means that this 
procedure would be included in CPT code 34203. In this case, billing this procedure separately is not 
supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99199, 75710 and 37184 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 99199, 75710 and 37184. 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.