Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services coded 75774-59. We decided that the Plan does not have 
to pay for the services coded 75625.  
 
You asked the Plan to pay for the medical services coded 75774-59. You say that these codes are supported 
based on the medical records submitted. The Plan says that the documentation does not support payment for the 
services as billed. 
 
We decided that the Plan has to pay for the services coded 75774-59.  
 
The Plan follows 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 75774 is a 
column II code to column I code 37227; however, 75774 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 75774-59. Our reviewer says that the documentation 
supports the use of the 59 modifier to bypass the NCCI edit and support payment for the services billed. Our 
reviewer found that the documentation does support the use of procedure code 75774 as the left femoral artery 
is on another branch from the procedure code artery captured with procedure code 37227. 
 
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 medical services coded 75774-59 have been met. Therefore, we decided that 
the Plan has to pay for the services coded 75774-59.  
 
We also decided that the Plan does not have to pay for the services coded 75625. 
 
The Plan follows 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 75625 is aortography, abdominal, by serialography, 
radiological supervision and interpretation. 
 
We asked our coder 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 coded 75625. Our reviewer says that the 
documentation does not support payment for code 75625. Our physician reviewer found that the documentation 
not state the provider makes an incision in the groin and breaks the common femoral artery using a needle. He 
inserts a guide wire and advances a catheter through the guidewire into the femoral artery. The provider 
advances the catheter up to the abdominal aorta. He then injects a contrast into the vessel and takes several 
images via serial radiography technique." Nor does the documentation support Serialography: High speed 
radiological technique that takes images of a particular area at regular intervals. The documentation does not 
support payment for this CPT 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 coded 75625 have not been met. Therefore, we decided that the 
Plan does not have to pay for the services coded 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.