Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37220. We decided that the Plan does not have to pay for 37252 and 
37253.  
 
You asked the Plan to pay for procedure codes 37220, 37252, and 37253 rendered on January 9, 2023.. You 
say that this should be paid for. The Plan says that the records do not support the services billed. 
 We decided that the Plan has to pay for 37220.  
 
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 CPT 37220 is "Revascularization, endovascular, open or 
percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty." 
 
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 37220. Our reviewer says that there is 
satisfactory documentation that a severe stenosis of the proximal left common iliac artery was identified and 
underwent balloon angioplasty with excellent result. While the documentation lacks detail such as degree of 
stenosis pre and post angioplasty, the documentation meets a minimum threshold on which to justify use and 
coverage of CPT 37220.  
 
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 
37220.  
 
We also decided that the Plan does not have to pay for 37252 and 37253. 
 
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 the remaining codes is: 
 
CPT 37252: 
 
Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, 
including radiological supervision and interpretation; initial noncoronary vessel (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) 
 
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 37252 and CPT 37253. Our reviewer says that 
these codes are for supervision and interpretation of intravascular ultrasound (IVUS) imaging. There is 
inadequate detail with respect to IVUS findings that would justify the billing and coverage of these 
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 37252 and 37253 have not been met. Therefore, we decided that the Plan does 
not have to pay for 37252 and 37253. 
 
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.