Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 75625 and 75710. We decided that the Plan does not have to pay for 
37184.  
 
You asked the Plan to pay for procedure codes 37184, 75710, and 75625 provided to the enrollee on November 
22, 2021.. 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 75625 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. The definition of the overturned codes are: 
 
CPT 75710: 
 Aortography, abdominal, by serialography, radiological supervision and interpretation  
 
CPT 75625: 
 
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 75625 and 75710. Our reviewer says that CPT 
75625 codes for diagnostic aortogram.  Diagnostic angiography including the aortogram is separately billable if 
no previous angiography has recently been performed or if there was a change in condition. The documentation 
is consistent with these conditions being met. There is satisfactory documentation of the aortogram results to 
support its coverage. 
 
In terms of CPT 75710, this codes for diagnostic extremity angiography. Again, diagnostic angiography 
including the lower extremity angiogram, is separately billable if no previous angiography has recently been 
performed or if there was a change in condition. The documentation is consistent with these conditions being 
met.  There is satisfactory documentation of the lower extremity angiogram results to support its coverage. 
 
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 
75625 and 75710.  
 
We also decided that the Plan does not have to pay for 37184. 
 
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 37184 is "Primary percutaneous transluminal mechanical 
thrombectomy, noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance 
and intraprocedural pharmacological thrombolytic injection(s); initial vessel." 
 
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 37184. Our reviewer says that the 
documentation does not support the use of this code. There is inadequate documentation of the nature of the 
thrombus, whether this was a rescue thrombectomy, in which case a different code would be used, or even if 
a meaningful thrombectomy was performed. There are no details with respect to which device was used, or the 
outcome. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37184 have not been met. Therefore, we decided that the Plan does not have to 
pay for 37184. 
 
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.