Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 35371. We decided that the Plan does not have to pay for 36246 and 
37242.  
 
You asked the Plan to pay for surgical services (procedure codes 35371, 36246, 37242) provided to the enrollee 
on June 9, 2022.. You say that this should be paid for. The Plan says that the records do not support the 
services billed. 
 
We decided that the Plan has to pay for 35371.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 35371 is 
"Thromboendarterectomy, including patch graft, if performed; common femoral." 
 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 35371. Our physician reviewer found that the 
patient underwent endovascular repair with an aorto-bi-iliac device for the treatment of bilateral common iliac 
artery aneurysms.  The right groin access was treated percutaneously and billed as such and covered.  On the 
left, once percutaneous access closure failed, open repair was required necessitating femoral endarterectomy 
and patch angioplasty. Extensive repair and endarterectomy of the femoral artery is separately reportable and 
there is satisfactory documentation that the work included in code 35371 was performed. 
 
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 
35371.  
 
We also decided that the Plan does not have to pay for 36246 and 37242. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of the rest of the denied codes is: 
 
CPT 36246: 
 
Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery 
branch, within a vascular family 
 
CPT 37242: 
 
Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural 
roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or 
tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, 
aneurysms, pseudoaneurysms) 
 
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 36246 and CPT 37242. Our doctor found that 
additional treatments within the endograft treatment zone is not separately reportable. As the catheterization as 
coded by 36246, and embolization as coded by 37242 were both performed within the common iliac artery (the 
treatment zone of the endograft) they are not separately reportable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 36246 and 37242 have not been met. Therefore, we decided that the Plan does 
not have to pay for 36246 and 37242. 
 
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.