Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37248, 37249, 75822, and 75825. We decided that the Plan does not 
have to pay for 37241.  
 
You asked the Plan to pay for procedure codes 37241, 37248, 37249, 75822, and 75825 rendered on September 
6, 2022.. 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 37248, 37249, 75822, and 75825.  
 
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 overturned codes is: 
 
CPT 37248: 
 
Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and 
radiological supervision and interpretation necessary to perform the angioplasty within the same vein; initial 
vein 
 
CPT 37249: 
 
Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and 
radiological supervision and interpretation necessary to perform the angioplasty within the same vein; each 
additional vein (List separately in addition to code for primary procedure) 
 
CPT 75822: 
 
Venography, extremity, bilateral, radiological supervision and interpretation 
 
CPT 75825: 
 
Venography, caval, inferior, with serialography, 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 these codes. Our reviewer says that CPT 37248 and 
CPT 27249 codes for venous balloon angioplasty. There is satisfactory documentation that multiple (separate) 
veins underwent balloon angioplasty, therefore the billing and coverage of both of these codes is justified. 
 
CPT 75822 and CPT 75825 code for venous angiography of the inferior vena cava (IVC) and bilateral 
extremities. There is satisfactory documentation that these territories were imaged with satisfactory description 
of findings. 
 
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 
37248, 37249, 75822, and 75825.  
 
We also decided that the Plan does not have to pay for 37241. 
 
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 37241 is "Vascular embolization or occlusion, inclusive 
of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance 
necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous 
malformations, venous and capillary hemangiomas, varices, varicoceles)." 
 
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 37241.  Our reviewer says that this codes for embolization of a venous condition, not hemorrhage. In this case, the 
embolization was performed for hemorrhage. CPT 37241 would not apply in this situation and is the incorrect 
code for the procedure performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37241 have not been met. Therefore, we decided that the Plan does not have to 
pay for 37241. 
 
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.