Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37225. We decided that the Plan does not have to pay for 37229 and 
37232.  
 
You asked the Plan to pay for the revascularization (37225, 37229 and 37232) provided on August 23, 2022.. 
You say that the claim should be paid. The Plan says that the services are not supported by the records. 
 
We decided that the Plan has to pay for 37225.  
 
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 37225 is Revascularization, endovascular, open or 
percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same 
vessel, when performed. 
 
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 to pay for the services. Our reviewer says that the 
medical records do support the use of procedure code 37225 as the revascularization was successful. 
 
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 
37225.  
 
We also decided that the Plan does not have to pay for 37229 and 37232. 
 
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 37229 is Revascularization, endovascular, open or 
percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the 
same vessel, when performed. The definition of code 37232 is Revascularization, endovascular, open or 
percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (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 to pay for 37229 and 37232. Our reviewer says that the 
medical documentation supports that procedure code 37229 was attempted but it was unsuccessful in passing 
into the distal peroneal artery, therefore this procedure code 37229 is not fully completed and therefore is not 
billable. The medical records do not support the use of procedure code 37232 as the revascularization was 
unsuccessful. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37229 and 37232 have not been met. Therefore, we decided that the Plan does 
not have to pay for 37229 and 37232. 
 
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.