Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 17, 2022, billed with 
codes 37239, 37248-59, 75822-59, 75825-59, and 36005-59. 
 
You asked the Plan to pay for the services as billed. You say that this should be paid as billed. The Plan denied 
your request. The Plan says some line items were approved for payment; however, the remaining are denied as 
not supported.  
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 37239 is Transcatheter placement of an intravascular 
stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty 
within the same vessel, when performed; each additional vein (List separately in addition to code for primary 
procedure). The definition of 37248 is Transluminal balloon angioplasty (except dialysis circuit), open or 
percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the 
angioplasty within the same vein; initial vein. The definition of 75822 is Venography, extremity, bilateral, 
radiological supervision and interpretation. The definition of 75825 is Venography, caval, inferior, with 
serialography, radiological supervision and interpretation. Lastly, the definition of 35005 is Injection procedure 
for extremity venography (including introduction of needle or intracatheter). 
 
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 services as billed. Our reviewer says that the services 
reported on the claim are not supported by the records. Our reviewer found for code 37239, the report does not 
include enough documentation to confirm per NCCI Policy "In the percutaneous approach, a guidewire is 
threaded through the needle into the blood vessel and the needle is removed".  Operative report documents " 
"Two 14 mm x 150 mm Abre kissing stents were deployed from the IVC to the bilateral external iliac veins. 
Postprocedural intravascular ultrasound demonstrated significant improvement in flow bilaterally." 
 
For 37248, the operative report describes angioplasty, however, this procedure would be included in CPT 
37238, as per code description "including angioplasty with the same vessel".  Therefore, modifier -59 is not 
supported. Codes 75822 and 75285 are not supproted with modifier -59 as the radiology interpretation is 
included in the overall intervention procedure. Code 36005 is also included in the overall procedure and cannot 
be separate with modifier -59. 
 
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 services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on May 17, 2022, billed with codes 37239, 37248-59, 
75822-59, 75825-59, and 36005-59.