Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 75625 and 75710. We decided that the Plan does not have to pay for 
37232 and 75736.  
 
You asked the Plan to pay for procedure codes 37232, 75625, 75710 and 75736 rendered on July 15, 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 75625 and 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.  
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 75625 and CPT 75710. Our reviewer says that 
CPT 75626 codes for "aortography, abdominal, by serialography, radiological supervision and interpretation." 
In this case, there is documentation of the status of the distal aorta and its major branches, the iliac 
arteries. Although it is an incomplete aortogram, sufficient description is provided to justify use of code 
75625. CPT 75710 codes for "angiography, extremity, unilateral, radiological supervision and interpretation." 
There is satisfactory documentation of extremity diagnostic findings to justify use 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 
75625 and 75710.  
 
We also decided that the Plan does not have to pay for 37232 and 75736. 
 
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 37232 and CPT 75736. Our reviewer says that 
CPT 37232 is an add-on code for "revascularization, endovascular, open or percutaneous, tibial/peroneal artery, 
unilateral, each additional vessel; with transluminal angioplasty (List separately in addition to code for primary 
procedure)." It signifies angioplasty of an additional tibial artery after an initial tibial percutaneous transluminal 
angioplasty (PTA). The plan approved coverage of PTA of one tibial artery as there is documentation of 
angioplasty of the proximal portion of the posterior tibial artery. The documentation does not indicate that a 
meaningful angioplasty of the anterior tibial artery was performed on which to overturn the health plan 
determination. Attempted but failed procedures are generally not billable.  
 
In terms of CPT 75736, this codes for "angiography, pelvic, selective or supraselective, radiological 
supervision and interpretation." There is no documentation that selective pelvic views were necessary or 
performed. Coverage of both the aortogram and pelvic angiography would be inappropriate based on the 
documentation provided.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37232 and 75736 have not been met. Therefore, we decided that the Plan does 
not have to pay for 37232 and 75736. 
 
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.