Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 75710. We decided that the Plan does not have to pay for 37220 and 
37625.  
 
You asked the Plan to pay for procedure codes 37220, 75625, and 75710 provided to the enrollee on May 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 75710.  
 
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 
CPT 75710 is "Angiography, extremity, unilateral, radiological supervision and interpretation." 
 
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 75710. Our reviewer says that this codes for 
unilateral extremity angiography that can be separately billable if there was no prior angiography.  In this case, 
there is no clear evidence that recent left lower extremity angiography was performed. The description of the 
angiogram meets the minimum level to justify billing and coverage of this code. 
 
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 
75710.  
 
We also decided that the Plan does not have to pay for 37220 and 37625. 
 
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 still denied codes is: 
 
CPT 37220: 
 
Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal 
angioplasty 
 
CPT 75625: 
 
Aortography, abdominal, by serialography, radiological supervision and interpretation 
 
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 37220 and 37625. Our reviewer says that CPT 
37220 is a base code for iliac percutaneous transluminal angioplasty. Only one base code for an iliac territory 
can be used. In this case, the base code CPT 37221 - coding for common iliac artery stenting - was billed and 
covered. Treatment of the external iliac artery in this setting requires an add-on code, not a base 
code. Therefore, CPT 37220 is inappropriate. 
 
Additionally, CPT 37625 codes for aortogram and is separately billable if no previous angiography was 
performed. There is documentation that the patient had a recent procedure that more likely than not included 
aortography. There is no documentation that there was no previous angiography. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37220 and 37625 have not been met. Therefore, we decided that the Plan does 
not have to pay for 37220 and 37625. 
 
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.