Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 37184 and 37185. We decided that the Plan does not 
have to pay for procedure codes 75716, 75625, and 75774. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan says that the 
services are not covered. 
 
We decided that the Plan has to pay for procedure codes 37184 and 37185. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that procedure codes 37184 and 37185 are column II codes with 
a modifier indicator of 1 when billed with column I code 37227; however, there are no active National Correct 
Coding Initiative (NCCI) edits for these codes. The Plan has not provided any documentation or Medicare rules 
to support that the codes are not payable as billed. Therefore, we decided that the Plan has to pay for procedure 
codes 37184 and 37185 rendered on September 21, 2021. 
 
We also decided that the Plan does not have to pay for procedure codes 75716, 75625, and 75774. 
 
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 37233 is 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). The 
definition of code 75625 is aortography, abdominal, by serialography, radiological supervision and 
interpretation. 
 
We find that CPT codes 37233 and 75625 are not supported in the medical record. Specifically, there is no 
documentation of an open or percutaneous endovascular revascularization of unilateral tibial/peroneal artery to 
support code 37233. There is no documentation of radiological supervision and interpretation of an abdominal 
aorthography by serialography to support code 75625. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 37227 (revascularization, endovascular, open or 
percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, 
includes angioplasty within the same vessel, when performed), 75716 (angiography, extremity, bilateral, 
radiological supervision and interpretation) and 75774 (angiography, selective, each additional vessel studied 
after basic examination, radiological supervision and interpretation [List separately in addition to code for 
primary procedure]). Codes 75716 and 75774 are column II codes with a modifier indicator of 1 when billed 
with column I code 37227. The column II codes were not billed with appropriate modifiers to allow for 
separate payment. The -XU modifier is not supported as separate and distinct procedural service. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 75716, 75625, and 75774 
rendered on September 21, 2021. 
 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.