Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37232. We decided that the Plan does not have to pay for 37253 and 
75710.  
 
You asked the Plan to pay for angiography, intravascular ultrasound, and endovascular revascularization 
provided to the enrollee on April 18, 2021. You say that this should be paid for. The Plan says that the records 
do not support the services billed. 
 
 The definition of the denied codes is: 
 
CPT 37232: 
 
Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; 
with transluminal angioplasty (List separately in addition to code for primary procedure) 
 
CPT 37253: 
 
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) 
 
CPT 75710: 
 
Angiography, extremity, unilateral, radiological supervision and interpretation 
 
We decided that the Plan has to pay for 37232.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 CPT 37232. Our reviewer says that CPT 37232 is 
an add-on code coding for an additional tibial artery angioplasty after the initial tibial angioplasty. In this case, 
the operative note documents angioplasty of the anterior tibial artery and CPT code 37228 was billed and 
approved. In addition, there is satisfactory documentation that the tibial peroneal trunk was also angioplastied 
and, therefore, use of the add-on code CPT 37232 is appropriate.  
 
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 have been met. Therefore, we decided that the Plan has to pay for 
37232.  
 
We also decided that the Plan does not have to pay for 37253 and 75710. 
 
The Plan must follow Medicare rules. Providers must report services with the appropriate CPT code. The rules 
state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a 
distinct procedural service.  
 
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 CPT 37253 and CPT 75710. Our reviewer says that 
the superficial femoral artery and popliteal artery are considered to be a single-vessel for the purpose of coding; 
the provider billed for 37252 for IVUS of the SFA/popliteal artery and this was approved. There is no 
documentation that additional arteries underwent intravascular ultrasound (IVUS), and therefore agree with 
denial of 37253 - the add-on code used to bill for additional arteries that underwent IVUS after the initial 
artery. CPT 37227 is a bundled code (has been approved) that includes work done for supervision and 
interpretation of the angiographic images.  Therefore, CPT code 75710 (codes for supervision and 
interpretation of the angiographic images) is not separately billable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37253 and 75710 have not been met. Therefore, we decided that the Plan does 
not have to pay for 37253 and 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.