Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 75726. We decided that the Plan does not have to pay for 36248 and 
75774.  
 
You asked the Plan to pay for angiography and selective catheter placement provided to the enrollee on June 3, 
2022.. 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 36248: 
 
Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, 
pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or 
third order vessel as appropriate)  
CPT 75726: 
 
Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision 
and interpretation 
 
CPT 75774: 
 
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and 
interpretation (List separately in addition to code for primary procedure) 
 
We decided that the Plan has to pay for 75726.  
 
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 75726. Our reviewer says that this codes for 
visceral angiography. There is satisfactory documentation of a visceral angiogram provided in the operative 
note. For embolization procedures, catheterization and diagnostic angiography is 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 the services have been met. Therefore, we decided that the Plan has to pay for 
75726.  
 
We also decided that the Plan does not have to pay for 36248 and 75774. 
 
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 36248 and CPT 75774. Our reviewer says that 
in terms of CPT 36248, this codes for an additional second or third order catheterization.  The documentation 
describes two second or third order cannulations, namely the left colic and the superior rectal. These 
catheterizations have already been billed and covered. There is no documentation that a third second or third 
order catheterization was performed. Catheterization of the IMA on the way to catheterizing more selective 
arteries is not billable. For CPT 75774, this codes for additional vessel angiography. The documentation does 
not provide sufficient detail describing additional angiography to justify additional supervision and 
interpretation codes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 36248 and 75774 have not been met. Therefore, we decided that the Plan does 
not have to pay for 36248 and 75774. 
 
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.