Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37222 and 37224. We decided that the Plan does not have to pay for 
75716 and 75625.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that the denied 
codes remain not supported. 
 
We decided that the Plan has to pay for CPT 37222 and 37224.  
 
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 approved codes is: 
 
 CPT 37222: 
 
Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with 
transluminal angioplasty (List separately in addition to code for primary procedure) 
 
CPT 37224: 
 
Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with 
transluminal angioplasty 
 
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 these surgical codes. Our reviewer says that these 
services were supported in the medical records. Our physician reviewer found that the documentation does 
support CPT 37222, intervention on the left external iliac artery, and the left common iliac artery. This code is 
to be reported for each additional vessel on the ipsilateral side. Additionally, the documentation  does support 
CPT 37224, intervention on the left common femoral artery. The records support that these services were 
rendered 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 37222 and 37224 have been met. Therefore, we decided that the Plan has to pay 
for 37222 and 37224.  
 
We also decided that the Plan does not have to pay for CPT 75716 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. In this case, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 75625: 
 
Aortography, abdominal, by serialography, radiological supervision and interpretation 
 
CPT 75716: 
 
Angiography, extremity, bilateral, radiological supervision and interpretation 
 
We looked at the file and Medicare rules. An edit exists between CPT 75716 and 37220, as well as CPT 75625 
and 93459. An appropriate modifier was not included on the claim to bypass these edits. Based on this 
information, we decided that Medicare rules for coverage of 75716 and 75625 have not been met. Therefore, 
we decided that the Plan does not have to pay for 75716 and 75625. 
 
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.