Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37253. We decided that the Plan does not have to pay for 37229, 
37233, 75625, and 75710.  
 
You asked the Plan to pay for procedure codes 37229, 37233, 37253, 75625, and 75710 rendered on January 
26, 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 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 
CPT 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 for CPT 37253. Our reviewer says that there is 
documentation that intravascular ultrasound (IVUS) was performed on an additional artery after an initial 
artery where absence of significant disease is confirmed. Therefore, CPT 37253 is confirmed to be supported. 
 
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 
37253.  
 
We also decided that the Plan does not have to pay for 37229, 37233, 75625, and 75710. 
 
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: 
 
CPT 37229: 
 
Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with 
atherectomy, includes angioplasty within the same vessel, when performed 
 
CPT 37233: 
 
Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; 
with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to 
code for primary procedure) 
 
CPT 75625: 
 
Aortography, abdominal, by serialography, radiological supervision and interpretation 
 
CPT 75710: 
 
Angiography, extremity, unilateral, 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 codes. Our reviewer says that in terms of CPT 
75625 and CPT 75710, diagnostic angiography codes of the aorta and unilateral extremity may be separately 
billed and covered if there is documentation that no recent previous angiography is available or if there was a 
change in condition. As there is documentation that the enrollee had recent angiographic imaging, the codes are 
not supported. There is evidence that the enrollee had bilateral signs and symptoms at the time of recent 
previous angiography; therefore, the codes are not verified. 
 
In terms of CPT 37229 and 37233, the documentation of the angiographic findings post-intervention does not 
satisfactorily demonstrate that meaningful atherectomy and angioplasty were performed on the tibial arteries. There is no description in the body of the operative report why 2mg of tissue plasminogen activator 
(TPA) was used or what the result of the TPA was. Attempted but unsuccessful interventions are not coverable. 
Therefore, the codes are not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37229, 37233, 75625, and 75710 have not been met. Therefore, we decided that 
the Plan does not have to pay for 37229, 37233, 75625, and 75710. 
 
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.