Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services. We decided that the Plan does not have to pay for 37252.  
 
You asked the Plan to pay for procedure codes 36245, 36252, 37252, and 75726 rendered on January 7, 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 the services.   
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 36245: 
 
Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery 
branch, within a vascular family 
 
CPT 36252: 
 
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; bilateral 
 
CPT 75726: 
 
Angiography, visceral, selective or supraselective (with or without flush aortogram), 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 services. Our reviewer says that in terms of 
CPT 36245 and 75726, there is documented of selective access of the inferior mesenteric artery (IMA) with 
associated angiography. There is satisfactory documentation of the findings. This work is not bundled with the 
intervention code and is separately billable. In terms of CPT 36252, there is documentation of bilateral renal 
artery catheterization and angiography with satisfactory documentation 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 
the services.  
 
We also decided that the Plan does not have to pay for 37252. 
 
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 37252 is "Intravascular ultrasound (IVUS) (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)." 
 
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. Our reviewer says that this codes for 
supervision and interpretation of IVUS imaging of a vessel. There is inadequate documentation of IVUS 
findings on which to justify billing and coverage of this code.  
 
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 have not been met. Therefore, we decided that the Plan does not have to 
pay for 37252. 
 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.