Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37225. We decided that the Plan does not have to pay for 37252 and 
37253.  
 
You asked the Plan to pay for procedure codes 37225, 37252, 37253 rendered on February 17, 2023.. You say 
that  The Plan says that   
We decided that the Plan has to pay for 37225.  
 
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 37225 is "Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; 
with atherectomy, 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 37225. Our reviewer says that there is 
satisfactory documentation that the right common femoral artery had an occlusion. There is documentation that 
it was crossed with a medium Silver Hawk atherectomy device and that atherectomy was performed along with 
balloon angioplasty up to 7 mm. Although the description of the artery pre and post intervention lacks detail, 
the documentation meets the minimum threshold to justify coding and covering of CPT code 37225. 
 
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.  
 
We also decided that the Plan does not have to pay for 37252 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. In this case, the CPT Code Manual definition of 
the upheld codes are: 
 
CPT 37252: 
 
Intravascular ultrasound (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) 
 
CPT 37253: 
 
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 for these codes. Our reviewer says that there is 
unsatisfactory documentation of the intravascular ultrasound (IVUS) interpretation. Therefore, the use of these 
codes cannot be justified. 
 
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 and 37253 have not been met. Therefore, we decided that the Plan does 
not have to pay for 37252 and 37253. 
 
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.