Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for 75710. We decided that the Plan does not have to pay for 37235 and 
37253.  
 You asked the Plan to pay for procedure codes 37235, 37253, 75710 rendered on August 16, 2022.. You say 
that you submitted medical records for review. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 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 
CPT 75710 is "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 75710. Our reviewer says that this codes for 
supervision and interpretation of an extremity angiogram. This service is separately reportable and billable if 
there is no prior angiogram available or if there was a change in condition, and if there is satisfactory 
documentation of the diagnostic findings. In this case, there is no evidence of a recent prior angiogram and 
there is satisfactory detail with respect to the diagnostic findings to justify use of this code.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
75710.  
 
We also decided that the Plan does not have to pay for 37235 and 37253. 
 
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 37235: 
 
Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; 
with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when 
performed (List separately in addition to code for primary procedure) 
 
CPT 37253: 
 
Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, 
including radiological supervision and interpretation; each additional noncoronary vessel (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 37235 and CPT 37253. Our reviewer says that 
CPT 37235 is an add-on code, coding for atherectomy and stenting of an additional tibial artery after initial 
tibial atherectomy and stenting. A treatment, including atherectomy and stenting spanning the tibial peroneal 
truck and a tibial artery is considered one intervention. This has been already billed and covered. Billing for an 
additional tibial intervention in this setting would not be appropriate. In terms of CPT 37253, this is an add-on 
code, coding for the supervision and interpretation of the intravascular ultrasound (IVUS) findings for each 
additional artery after the initial. There is no satisfactory interpretation of IVUS findings to justify use of this 
code.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37235 and 37253 have not been met. Therefore, we decided that the Plan does 
not have to pay for 37235 and 37253. 
 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.