Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 75716. We decided that the Plan does not have to pay for 37228 and 
75625.  
 
You asked the Plan to pay for procedure codes 37228, 75625 and 75716 rendered on April 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 75716.  
 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 75716 is "Angiography, extremity, bilateral, 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 75716. Our reviewer says that this codes for 
supervision and interpretation of bilateral extremity angiography. This is separately billable and not bundled 
with the lower extremity treatment code if there is no recent prior angiogram available or if there was a change 
in condition, and if there is satisfactory documentation of diagnostic angiographic findings. In this case, there is 
satisfactory documentation that a diagnostic angiogram of the lower extremities was performed and interpreted, 
and there is no evidence of recent prior angiography. 
 
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 
75716.  
 
We also decided that the Plan does not have to pay for 37228 and 75625. 
 
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 remaining denied codes is: 
 
CPT 37228: 
 
Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with 
transluminal angioplasty 
 
CPT 75625: 
 
Aortography, abdominal, by serialography, 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 37228 and CPT 75625. Our reviewer says that 
CPT 37228 codes for tibial percutaneous transluminal angioplasty. There is documentation in the operative 
note that this was not accomplished, so coverage for this service would not be appropriate. In terms of CPT 
75625, this codes for the supervision and interpretation of an abdominal aortogram. The operative findings do 
not describe the status of the aorta nor renal arteries so coverage for this service would not be appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37228 and 75625 have not been met. Therefore, we decided that the Plan does 
not have to pay for 37228 and 75625. 
 
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.