Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37229, 37232 and 75625. We decided that the Plan does not have to 
pay for 75716, 37220, and 75774.  
 
You asked the Plan to pay for various vascular services provided to the enrollee on June 14, 2022.. You say 
that this should be paid for. The Plan says that the records do not support the services billed. 
 
The definition of the denied codes is: 
 
CPT 37220: 
 
Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal 
angioplasty 
 CPT 37229: 
 
Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with 
atherectomy, includes angioplasty within the same vessel, when performed 
 
CPT 37232: 
 
Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; 
with transluminal angioplasty (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 
 
CPT 75774: 
 
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and 
interpretation (List separately in addition to code for primary procedure) 
 
We decided that the Plan has to pay for 37229, 37232 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. 
 
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 37229 and 75625. Our reviewer says that CPT 
37229 codes for atherectomy with or without percutaneous transluminal angioplasty (PTA) of a tibial peroneal 
vessel. The documentation could be clearer; however, there is a description of a tibial peroneal trunk stenosis 
and some description of the tibial outflow, enough that the documentation barely meets a threshold to justify 
use of this code. CPT 75625 codes for diagnostic aortogram and is separately billable if there was no recent 
diagnostic study. As there is no evidence that a prior study exists and there is documentation that there is no 
recent prior study, this code is billable and there is sufficient description to justify its use. In terms of CPT 
37232, this codes for PTA of an additional tibial artery. In this case, there is documentation that there was 
disease in the distal peroneal artery and the area was angioplastied with a 2mm balloon with improvement in 
flow. While more detail should be expected, the documentation reaches a minimum threshold to justify its use.   
 
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 
37229, 37232 and 75625.  
 
We also decided that the Plan does not have to pay for 75716, 37220, 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. 
 
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, 37220, and 75774. Our reviewer says 
that CPT 75716 codes for supervision and interpretation of bilateral extremity angiography. As this was a unilateral imaging procedure, use of this code is not appropriate. CPT 37220 codes for non-selective aortic 
access. The access is bundled into the code for intervention that was billed and covered. It is not separately 
billable. CPT 75774 codes for additional angiography with separate catheterization. As no additional vessels 
were imaged besides those off the aorta and in the left lower extremity, the use of this code is not 
appropriate. A more appropriate code for unilateral extremity angiography is available and should be used.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 75716, 37220, and 75774 have not been met. Therefore, we decided that the 
Plan does not have to pay for 75716, 37220, and 75774. 
 
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.