Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for 75716. We decided that the Plan does not have to pay for 75774.  
 
You asked the Plan to pay for procedure codes 75716 and 75774 rendered on December 13, 2022.. You say 
that this should be paid for. The Plan says that the records do not support the services billed. 
 
 We decided that the Plan has to pay for 75716.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
CPT 75716 is "Angiography, extremity, bilateral, radiological supervision and interpretation." 
 
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 75716. Our reviewer says that diagnostic 
angiography is not a component of lower extremity atherectomy and is separately billable if there is no prior 
recent angiogram or if there was a change in condition. Additionally, there has to be satisfactory documentation 
of the diagnostic interpretation. In this case, there is documentation that no recent prior angiography related to 
this condition is available and there is satisfactory documentation of lower extremity angiographic findings 
bilaterally. Therefore, CPT 75716 is supported in the documentation. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
75716.  
 
We also decided that the Plan does not have to pay for 75774. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
CPT 75774 is "Angiography, selective, each additional vessel studied after basic examination, radiological 
supervision and interpretation (List separately in addition to code for primary procedure)." 
 
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 75774. Our reviewer says that there is not 
sufficient documentation that additional arteries beyond the bilateral lower extremity angiogram required 
separate access and interpretation. Therefore, CPT 75774 is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 75774 have not been met. Therefore, we decided that the Plan does not have to 
pay for 75774. 
 
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.