Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37225 and 37253. We decided that the Plan does not have to pay for 
36140, 36200, 75625, 75716.  
 
You asked the Plan to pay for procedure codes 36140, 36200, 37225, 37253, 75625, and 75716 rendered on 
September 29, 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 37225 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. 
 
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 37225 and CPT 37253. Our reviewer says that 
CPT code 37225 is supported. The record confirms that revascularization of the popliteal artery with 
artherectomy was performed during this encounter. There is no NCCI edit indicating this is a column 2 code 
with any other procedure performed. CPT code 37253 is also confirmed. The record supports that intravascular 
ultrasound was performed on 2 additional non-coronary vessels after the primary IVUS. There is no NCCI edit 
indicating this is a column 2 code with any other 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 the services have been met. Therefore, we decided that the Plan has to pay for 
37225 and 37253.  
 
We also decided that the Plan does not have to pay for 36140, 36200, 75625, 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. 
 
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 the rest of the codes. Our reviewer says that CPT 
36140 and CPT 36200 are not supported. The introduction of a needle or catheter is integral to the main 
procedure and cannot be reported separately in this case. CPT code 75625 is not supported. The record does not 
state that a separate diagnostic abdominal aortography was performed during this encounter. CPT code 75716 
is not supported. The record does not state that a separate and unrelated diagnostic angiography of the bilateral 
legs were performed during this encounter. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 36140, 36200, 75625, 75716 have not been met. Therefore, we decided that the 
Plan does not have to pay for 36140, 36200, 75625, 75716. 
 
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.