Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 75710. We decided that the Plan does not have to pay for 36247, 
36248, and 37243.  
 
You asked the Plan to pay for procedure codes 36247, 36248, 37243, and 75710 rendered on December 21, 
2022.. 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 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 CPT 75710 is "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 CPT 75710. Our reviewer says that there is 
satisfactory documentation of lower extremity findings. Therefore, CPT 75710 is supported in this case. 
 
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 
75710.  
 
We also decided that the Plan does not have to pay for 36247, 36248, and 37243. 
 
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 rest of the codes is : 
 
CPT 36247: 
 
Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower 
extremity artery branch, within a vascular family 
 
CPT 36248: 
 
Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, 
pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or 
third order vessel as appropriate) 
 
CPT 37243: 
 
Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural 
roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or 
infarction 
 
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 summary, it 
appears that most of the codes in question do not apply to the procedures that were actually documented.  
 
CPT 36247 and CPT 36248 both code for third order selective catheterizations. As the documentation does not 
demonstrate that third order catheterizations were performed. The documentation does not justify use or 
coverage of these codes. 
 
In terms of CPT 37243, this codes for embolization of tumor, organ ischemia, or infarction. There is no 
evidence in the documentation that any of these conditions were treated, so the codes were 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 36247, 36248, and 37243 have not been met. Therefore, we decided that the 
Plan does not have to pay for 36247, 36248, and 37243. 
 
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.