Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 37253. We decided that the Plan does not have to pay 
for procedure code 75710.  
 
You asked the Plan to pay for procedure codes 37253 and 75710 billed for date of service June 8, 2022. You 
say that the services at issue were billed correctly. The Plan says that rules for payment have not been met. 
 
We decided that the Plan has to pay for procedure code 37253.  
 
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 code 37253 is "Intravascular ultrasound (noncoronary vessel) 
during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 37253. Our reviewer says that procedure 
code 37253 meets criteria for payment. Our reviewer found that the available documentation does support the 
use of procedure code 37253 as intravascular ultrasound was used to access additional vessels after the initial 
vessel was accessed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 37253 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 37253.  
 
We also decided that the Plan does not have to pay for procedure code 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, we have confirmed that code 75710 is a column II code to column I code 37229; however, 75710 
was billed with a modifier. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 75710. Our reviewer says that procedure 
code 75710 does not meet criteria for payment. Our reviewer found that an edit exists between procedure codes 
75710 and 37229. Medical documentation does not support the use of procedure 75710 with modifier XU to 
indicate a distinct and non-overlapping service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 75710 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 75710. 
 
  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.