Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for CPT 76937. We decided that the Plan does not have to pay for CPT 
37814, 37185, and 75827.  
 
You asked the Plan to pay for surgical and related services provided to the enrollee on October 1, 2021.. You 
say that this should be paid for. The Plan says that the records do not support the services billed. 
 
We find that the definition of the denied codes is: 
 
CPT 37184: 
 
Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, arterial or 
arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic 
injection(s); initial vessel  
CPT 37185: 
 
Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, arterial or 
arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic 
injection(s); second and all subsequent vessel(s) within the same vascular family (List separately in addition to 
code for primary mechanical thrombectomy procedure) 
 
CPT 75827: 
 
Venography, caval, superior, with serialography, radiological supervision and interpretation 
 
CPT 76937: 
 
Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent real time ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary procedure) 
 
We decided that the Plan has to pay for 76937.  
 
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 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 76937 Our reviewer says that this code is 
appropriate billed, as ultrasound guidance was used in this case. 
 
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 
76937.  
 
We also decided that the Plan does not have to pay for 37814, 37185, and 75827. 
 
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 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 the rest of the codes. Our reviewer says that 
procedure code 37184 is not supported by the medical records submitted. The operative report did not include 
documentation of a primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-
intracranial, from an arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural 
pharmacological thrombolytic injection(s), for the initial vessel. Codes 37184 and 37185 should not be used to 
report mechanical thrombectomy performed to remove short segments of thrombus or embolus discovered 
during other percutaneous interventional procedures, see 37186. There is also an edit with procedure code 
75827 with 37248 and it would not be appropriate as the procedures were not distinct and separate from each 
other 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37814, 37185, and 75827 have not been met. Therefore, we decided that the 
Plan does not have to pay for 37814, 37185, and 75827. 
 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.