Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 35302 and 37221. We decided that the Plan does not have to pay for 
37223.  
 
You asked the Plan to pay for procedure codes 35302, 37221, 37223 rendered on January 20, 2023.. You say 
that this should be paid for. The Plan says that the procedure codes are not supported by the medical records 
submitted.  
We decided that the Plan has to pay for 35302 and 37221.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of the overturned codes is: 
 
CPT 35302: 
 
Thromboendarterectomy, including patch graft, if performed; superficial femoral artery 
 
CPT 37221: 
 
Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal 
stent placement(s), includes angioplasty within the same vessel, when performed 
 
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 35302 and CPT 37221. Our reviewer says that 
the operative note was available for this review. It was apparently not available at the time of initial denial of 
coverage. In this case, there is satisfactory documentation that a femoral endarterectomy was performed and, as 
it involved the superficial femoral artery (SFA), the use of CPT 35302 is applicable.  
 
In terms of CPT 37221, similarly, there is satisfactory documentation that an iliac angioplasty and stenting was 
performed. Therefore, CPT 37221 is appropriate. 
 
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 
35302 and 37221.  
 
We also decided that the Plan does not have to pay for 37223. 
 
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 definition of CPT 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)." 
 
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 37223. Our reviewer says that stenting of a 
lesion of the common iliac artery that extends into the external iliac artery is considered a single element. In 
this case, the add on code for the additional iliac artery angioplasty and stenting is not separately billable.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37223 have not been met. Therefore, we decided that the Plan does not have to 
pay for 37223. 
 
 
 
 
 
 
 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.