Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 1 unit of procedure code 37253. We decided that the Plan does not have 
to pay for an additional unit of procedure code 37253.  

You asked the Plan to pay for 2 units of procedure code 37253. You say that the code should be paid per 
guidelines. The Plan says that the records do not support the billed code. 
 
We decided that the Plan has to pay for 1 unit of procedure code 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. 
 
In this case, the CPT Code Manual definition of code 37253 is intravascular ultrasound (noncoronary vessel) 
during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; each additional 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 to pay for 1 unit of procedure code 37253. Our 
physician reviewer found that there is satisfactory documentation of an intravascular ultrasound (IVUS) being 
performed at the initial superficial femoral artery (SFA). This was billed and covered as code 37252. There is 
also satisfactory documentation of IVUS of a single additional vessel (the tibial-peroneal trunk) where a critical 
stenosis was documented to have been identified by IVUS. There is insufficient documentation to support 
coverage of IVUS of further additional vessels. Therefore, the documentation does support coverage of a single 
unit of 37253.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 1 unit of procedure code 37253 have been met. Therefore, we decided that the 
Plan has to pay for 1 unit of procedure code 37253 billed for date of service April 19, 2023.  
 
We also decided that the Plan does not have to pay for an additional unit of procedure code 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 to pay for an additional unit of procedure code 37253. 
Our physician reviewer found that there is insufficient documentation to support coverage of IVUS of further 
additional vessels. Therefore, the documentation does not support a second unit of 37253.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 1 unit of procedure code 37253 have not been met. Therefore, we decided that 
the Plan does not have to pay for an additional unit of procedure code 37253 billed for date of service April 19, 
2023. 
 
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.