Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 34713-RT-XS, 36251-LT-XS, 37237-XS 
x2, 37224-LT-XS, 37221-RT-XS, 37223-RT-XS, and 75710-26-XU provided to December 14, 2022. 
 
You asked the Plan to pay for procedure codes 34713-RT-XS, 36251-LT-XS, 37237-XS x2, 37224-LT-XS, 
37221-RT-XS, 37223-RT-XS, and 75710-26-XU. You say that the medical records support the billing of 
procedure codes 34713-RT-XS, 36251-LT-XS, 37237-XS x2, 37224-LT-XS, 37221-RT-XS, 37223-RT-XS, 
and 75710-26-XU The Plan denied your request. The Plan says the medical records do not support the billing 
of procedure codes 34713-RT-XS, 36251-LT-XS, 37237-XS x2, 37224-LT-XS, 37221-RT-XS, 37223-RT-XS, 
and 75710-26-XU 
 
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 code 34713 is Percutaneous access and closure of femoral 
artery for delivery of endograft through a large sheath (12 French or larger), including ultrasound guidance, 
when performed, unilateral (List separately in addition to code for primary procedure). The definition of code 
36251 is Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal 
angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image 
postprocessing, permanent recording of images, and radiological supervision and interpretation, including 
pressure gradient measurements when performed, and flush aortogram when performed; unilateral. The 
definition of code 37237 is Transcatheter placement of an intravascular stent(s) (except lower extremity 
artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or 
coronary), open or percutaneous, including radiological supervision and interpretation and including all 
angioplasty within the same vessel, when performed; each additional artery (List separately in addition to code 
for primary procedure). The definition of code 37224 is Revascularization, endovascular, open or percutaneous, 
femoral, popliteal artery(s), unilateral; with transluminal angioplasty. The definition of code 37221 is 
Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal 
stent placement(s), includes angioplasty within the same vessel, when performed. The definition of code 37223 is Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; 
with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List 
separately in addition to code for primary procedure). The definition of code 75710 is Angiography, extremity, 
unilateral, radiological supervision and interpretation. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 34713-RT-XS, 36251-LT-XS, 37237-XS 
x2, 37224-LT-XS, 37221-RT-XS, 37223-RT-XS, and 75710-26-XU. Our reviewer says that the medical 
records do not support the billing of procedure codes 34713-RT-XS, 36251-LT-XS, 37237-XS x2, 37224-LT-
XS, 37221-RT-XS, 37223-RT-XS, and 75710-26-XU Our reviewer found based on the documentation 
provided, procedure code 34713 does not meet criteria. The procedure report documents "the 20-French 
DrySeal sheath was able to be placed in the aorta and in the aneurysm itself".  Although, this procedure is 
documented in the procedure report, this procedure would be included in procedure code 36245 Selective 
catheter placement.  In this case, this procedure and modifier cannot be verified, as it is not supported in the 
report. 
 
Procedure code 36251 does not meet criteria. The operative report describes an attempted procedure, which 
was not carried out due to complication. Therefore, this procedure cannot be verified, as performed. 
 
Procedure code 37237 does not meet criteria. The procedure report does not describe Transcatheter placement 
of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial 
vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological 
supervision and interpretation and including all angioplasty within the same vessel, when performed; each 
additional artery per NCCI Policy "The physician places one or more intravascular stents through a catheter 
into an artery other than a coronary, cervical or intrathoracic carotid, extracranial vertebral, iliac, intracranial, 
or lower extremity arthery.  The procedure may be performed via a percutaneous or an open approach.  In the 
percutaneous approach, a guidewire is threaded through the needle into the blood vessel and the needle is 
removed.  In the open approach, the physician makes an incision in the skin overlying the vessel to be 
catheterized.  The vessel is dissected and nicked with a small blade.  After the approach, a catheter with a stent-
transporting the tip is threaded over the guidewire into the vessel and the wire is extracted. The cateter travels 
to the point where the vessel needs additional support.  The compressed stent is passed from the cateter out into 
the vessel, where it deploys, expanding to support the vessel walls".  The operative report does not include 
documentation to support the procedure code. 
 
Procedure code 37224 does not meet criteria.  Procedure report describes stent placement with intervention.  In 
this case, the stent placement with intervention would be reported.  Therefore, this procedure code and modifier 
cannot be verified. 
 
Procedure code 37221 does not meet criteria.  The procedure report describes stent placement with 
intervention.  In this case, the stent placement with intervention would be reported.  Therefore, this procedure 
code and modifier cannot be verified. 
 
Procedure code 37223 does not meet criteria.  The procedure report describes stent placement with 
intervention.  In this case, the stent placement with intervention would be reported.  Therefore, this procedure 
code and modifier cannot be verified. 
 
Procedure code 75710 does not meet criteria.  In this case, an intervention was performed, which includes 
angio/venograms. Therefore, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 34713-RT-XS, 36251-LT-XS, 37237-XS x2, 37224-LT-XS, 
37221-RT-XS, 37223-RT-XS, and 75710-26-XU have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 34713-RT-XS, 36251-LT-XS, 37237-XS x2, 37224-LT-XS, 37221-RT-
XS, 37223-RT-XS, and 75710-26-XU provided to December 14, 2022.