Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37223. We decided that the Plan does not have to pay for 37225 and 
37229.  
 
You asked the Plan to pay for revascularization (procedure codes 37223, 37225, 37229) services provided to 
the enrollee on June 27, 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 37223.  
 
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 37222 is "Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral 
iliac vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (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 37223. Our reviewer says that this code is an 
add-on code for an additional ipsilateral iliac stent in addition to the initial iliac stent. In this case there is 
satisfactory documentation of a common iliac artery stent, this was billed and covered. There is also 
satisfactory documentation that a separate stent was placed in the left external iliac artery coded as CPT 37223. 
 
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 
37223.  
 
We also decided that the Plan does not have to pay for 37225 and 37229. 
 
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 
the denied codes is: 
 
CPT 37225: 
 
Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with 
atherectomy, includes angioplasty within the same vessel, when performed 
 
CPT 37229: 
 
Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with 
atherectomy, includes angioplasty within the same vessel, when performed 
 
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 37225 and CPT 37229 Our reviewer says that 
these codes are for atherectomy with or without balloon angioplasty of the femoral popliteal territory and tibial 
peroneal territories respectively. The documentation with respect to these procedures is too vague to support 
overturning the health plans determination. The degree of stenosis pre-intervention and subsequent results of 
the procedure are not sufficiently described 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37225 and 37229 have not been met. Therefore, we decided that the Plan does 
not have to pay for 37225 and 37229. 
 
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.