Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37253 and 75625. We decided that the Plan does not have to pay for 
37225, 75716, and 76942.  
 
You asked the Plan to pay for procedure codes 37225, 37253, 75625, 75716, 76942 provided to the enrollee on 
May 10, 2022.. You say that this should be paid for. The Plan says that the codes cannot be verified. 
 
We decided that the Plan has to pay for 37253 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 37253 and 75625.  Our reviewer says that the documentation does support the use of CPT 37253. The ultrasound was performed 
on the left superficial artery (SFA). This is the second ultrasound that was don. The first ultrasound was on the 
femoral artery. 
 
In terms of CPT 75625, the documentation does support this code. The provider lists that the omniflush was 
introduced into the aorta, and images were taken. At the bottom of the note, the provider interprets the images 
for diagnosis. 
 
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 
37253 and 75625.  
 
We also decided that the Plan does not have to pay for 37225, 75716, and 76942. 
 
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 37225, 75716, and 76942. Our reviewer says 
that the documentation does not support the use of CPT 37225, as the documentation supports a more 
appropriate code that describes the procedure being done with the bilateral iliac artery. 
 
In terms of CPT 75716, the medical documentation does not support reporting this code as separately 
identifiable from the approved procedure CPT 37229. There is an edit that exists between these codes, and the 
documentation does not support them as separately billable. 
 
Finally, in terms of CPT 76942, there is an edit between that code and CPT 37252. The documentation does not 
CPT 76942 as being able to be separately billed in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37225, 75716, and 76942 have not been met. Therefore, we decided that the 
Plan does not have to pay for 37225, 75716, and 76942. 
 
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.