Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded as 75716 and 36225 provided on March 24, 2021.

You asked the Plan to pay for the medical services. You say that you would like these services reprocessed based on the medical documentation. The Plan denied your request. The Plan says the services are not supported by the medical records submitted.

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 36225 is selective catheter placement, subclavian or innominate artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed.

The CPT Code Manual definition of code 75716 is angiography, extremity, bilateral, radiological supervision and interpretation. 

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 the medical services. Our reviewer says that the documentation does not support the services as billed. Our reviewer found that the medical records submitted do not include sufficient documentation to validate that 36225-50 was performed on March 24, 2021. Per the National Correct Coding Initiative Policy Manual for Medicare services regarding 36225, "The physician passes a needle through the skin and into an extremity artery. A guidewire is threaded through the needle into the vessel. The needle is removed. The wire is threaded into the thoracic aorta where it is manipulated into a branch off the aortic arch. A catheter follows the wire into the subclavian or innominate artery on one side. The wire is removed. Contrast material is injected into the catheter for arteriography, including the ipsilateral vertebral circulation. Angiography of the cervicocerebral arch may also be performed. Upon completion, the catheter is removed and pressure is applied to stop bleeding at the access site. When medically necessary, report moderate (conscious) sedation provided by the performing physician with 99151-99153. When provided by another physician, report 99155-99157. This code includes access of the vessel, placement of the catheter(s), injection(s) of the contrast, fluoroscopy, radiologic supervision and interpretation, and closure of the arteriotomy by pressure or by application of an arterial closure device. Diagnostic angiography may be followed by interventional procedures at the same operative session, and may be reported separately using appropriate coding guidelines. Do not report 36225 and 36226 together to report ipsilateral angiography. Report the single code that represents the most complex service, with 36226 being the most complex. Do not report with the transcatheter placement of an intravascular stent of the common carotid or innominate artery on the same side (37217). For 3D rendering, see 76376-76377. For ultrasound guidance for vascular access, see 76937." This description was not documented in the operative note as required for coverage. 

Furthermore, CPT 75716-XU is included with the services performed in CPT 37227. The medical records provided do not include sufficient documentation to validate that 75716 XU was performed as a distinct, separate service; therefore, 75716-XU is not eligible for additional reimbursement. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 75716 and 36225 provided on March 24, 2021.