Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 75716. We decided that the Plan does not have to pay for 31785.  
 
You asked the Plan to pay for vascular surgical services (procedure code 37185, 75716) provided to the 
enrollee on March 4, 2022. You say that this should be paid for. The Plan says that the denied codes remain not 
supported. 
 
We decided that the Plan has to pay for 75716.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 75716 is "Angiography, 
extremity, bilateral, radiological supervision and interpretation." 
 
 
 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 75716. Our reviewer says that there is 
satisfactory documentation that in the initial phase of the procedure, a bilateral angiogram was 
performed.  Although incomplete, there is enough description of the lower extremity arteries bilaterally to 
reach the threshold to qualify coding for 75716 -supervision and interpretation of bilateral extremity 
angiography. 
 
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 
75716.  
 
We also decided that the Plan does not have to pay for 31785. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 37185 is "Primary 
percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, arterial or arterial bypass 
graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); second 
and all subsequent vessel(s) within the same vascular family (List separately in addition to code for primary 
mechanical thrombectomy procedure)." 
 
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 31785. Our reviewer says that there is not 
satisfactory documentation to warrant coverage of code 37185, mechanical thrombectomy of an additional 
vessel. There is no documentation that the peroneal artery (this artery is alluded to in the provider appeal letter) 
was selectively accessed and no description of thrombus in any tibial artery and no details of the mechanical 
thrombectomy procedure or result. Therefore, a reasonable minimal threshold for coverage of 37185 has not 
been met and therefore unable to overturn the health plan determination for this 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 31785 have not been met. Therefore, we decided that the Plan does not have to 
pay for 31785. 
 
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.