Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; each additional vein (List separately in addition to code for primary procedure) represented by code 37239 and the Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure) represented by code 37253 provided on April 5, 2021.

You asked the Plan to pay for codes 37239 and 37253. You say that the medical records support the billing of codes 37239 and 37253 provided on April 4, 2021. The Plan denied your request. The Plan says that the medical records do not support the billing of codes 37239 and 37253 provided on April 4, 2021.

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 code 37239 is Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; each additional vein (List separately in addition to code for primary procedure). The definition of code 37253 is Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure).

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 codes 37239 and 37253. Our reviewer says that the medical records support the billing of codes 37239 and 37253 provided on April 4, 2021. Our reviewer found the operative note details the use of intravascular ultrasound imaging followed by stenting of both the right and left iliac veins. The CPT coding of these procedures is correct, and the medical records document the services (intravascular ultrasound (37253) followed by iliac stenting (37239) were both performed as described. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 37239 and 37253 have been met. Therefore, we decided that the Plan has to pay for the Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; each additional vein (List separately in addition to code for primary procedure) represented by code 37239 and the Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure) represented by code 37253 provided on April 5, 2021.

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.