Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound/revascularization/aortography services provided 
to the enrollee on April 26, 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 remain not supported. 
 
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 37220: 
 
Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal 
angioplasty 
 
 
 CPT 37222: 
 
Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with 
transluminal angioplasty (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) 
 
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 in terms of CPT 37220, was 
billed with the L modifier, indicated that the left was treated. As the records do not support that the left side 
was treated, it cannot be billed or covered. In terms of CPT 37222, only a single iliac lesion was treated. 
Regardless of if the balloon spans across from the common to the external iliac artery it is considered a single 
angioplasty. Therefore, based on the operative report, coding for an additional iliac artery angioplasty is not 
appropriate. In terms of CPT 37253, the operative note indicates use of intravascular ultrasound (IVUS) to 
characterize a single lesion; this was already billed and covered. There is no documentation that additional 
areas were interrogated by IVUS, therefore the documentation does not support the appropriateness of 
additional IVUS codes. In terms of CPT 75625, the operative note does not include sufficient detail of the 
aortogram to justify the work that this code is meant to bill for. In terms of CPT 75716, the operative note does 
not include sufficient detail of the angiogram to justify the work that this code is meant to bill for. 
 
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 ultrasound/revascularization/aortography services provided to the enrollee on April 26, 2022.