Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revascularization (37228-RT x 1 unit) and the 
angiography (75710-59 RT) provided on January 11, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
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, we have confirmed that code 75710 is a column II code to column I code 37227; however, 75710 
was billed with a modifier. 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 75710-59. Our reviewer 
found the documentation submitted was reviewed and does not meet criteria. The procedure was reported with 
modifier 59 distinct procedural service to bypass NCCI Edit. In this case, an intervention was performed, which 
includes radiological supervision and interpretation. The procedure report does not include documentation to 
support a distinct procedural service.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 75710-59 have not been met. 
 
For code 37728, the CPT Code Manual definition of code 37228 is revascularization, endovascular, open or 
percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty. 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 37228. Our reviewer found the documentation submitted for 37228 
was reviewed and does not meet criteria. The procedure report does not include sufficient documentation to 
confirm revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; 
with transluminal angioplasty was performed. To cite the report, "Catheter wire were navigated into the 
peroneal intravascular ultrasound was then used to adequately size treatment in the peroneal as well as the SFA 
popliteal". In this procedure, the provider restores the blood supply in the unilateral tibial or peroneal artery 
through an endovascular, open or percutaneous approach. He performs this procedure with transluminal 
angioplasty, a surgical procedure in which the provider places a balloon catheter at the site of an occlusion in 
the blood vessel and inflates the balloon to expand the lumen of the vessel. Use this code when the provider 
performs this procedure on the initial vessel. In this case, this procedure code 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 37228 have not been met. Therefore, we decided that the Plan does not have to 
pay for the revascularization (37228-RT x 1 unit) and the angiography (75710-59 RT) provided on January 11, 
2023.