Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36140, 36245, 36246 37225, 37229, 37233, 
75625 and 75716 provided to the enrollee on May 31, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes are not supported in the records submitted. 
 
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 36140: 
 
Introduction of needle or intracatheter, upper or lower extremity artery 
 
CPT 36245: 
 
Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family 
 
CPT 36246: 
 
Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery 
branch, within a vascular family 
 
CPT 37225: 
 
Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with 
atherectomy, includes angioplasty within the same vessel, when performed 
 
CPT 37229: 
 
Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with 
atherectomy, includes angioplasty within the same vessel, when performed 
 
CPT 37233: 
 
Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; 
with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to 
code for primary procedure) 
 
CPT 75625: 
 
Aortography, abdominal, by serialography, radiological supervision and interpretation 
 
CPT 75716: 
 
Angiography, extremity, bilateral, radiological supervision and interpretation 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 36140, 36245, 36246, and 
75716 were not documented as independent procedurds in this case. In terms of CPT 37225, an angiogram of 
the left lower extremity showed disease in the popliteal artery, the posterior tibial trunk, and the peroneal 
vessel. "Laser atherotomy was performed in the stenotic area followed by balloon angioplasty." Therefore, CPT 
37225 and 37233 were not supported in this case. Additionally, in terms of CPT 75625, the aortic angiogram of 
both iliac and femoral was open. Therefore, the records do not support the use of CPT 75625 in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 36140, 36245, 36246 37225, 37229, 37233, 75625 and 75716 provided to the 
enrollee on May 31, 2022.