Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 36247. We decided that the Plan does not have to pay for 37229 and 
75710.  
 
You asked the Plan to pay for procedure codes 36247, 37229 and 75710 provided to the enrollee on September 
19, 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 36247.  
 
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 36247 is "Selective catheter placement, arterial system; initial third order or more selective abdominal, 
pelvic, or lower extremity artery branch, within a vascular family." 
 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 36247. Our reviewer says that this review has 
determined the minimal level of documentation required to bill for atherectomy has not been met, the 
catheterization (that normally would be considered bundled with the atherectomy code) can be billed, as there 
is satisfactory documentation that a third order catheterization (right medial plantar artery) was performed.  
 
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 
36247.  
 
We also decided that the Plan does not have to pay for 37229 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. In this case, the CPT Code Manual definition of 
the still denied codes is: 
 
CPT 37229: 
 
Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with 
atherectomy, includes angioplasty within the same vessel, when performed 
 
CPT 75710: 
 
Angiography, extremity, unilateral, 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 37229 and CPT 75710. Our reviewer says that 
the documentation does not provide enough detail with respect to the appearance of the posterior tibial artery 
and its branches (either pre-or post-intervention) on which to support that meaningful atherectomy and 
angioplasty was, in effect, performed.  Similarly, there is insufficient description of the right lower extremity 
angiogram to justify billing and coverage of supervision and interpretation of an extremity angiogram.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37229 and 75710 have not been met. Therefore, we decided that the Plan does 
not have to pay for 37229 and 75710. 
 
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.