Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37220 and 75710. We decided that the Plan does not have to pay for 
36140.  
 
You asked the Plan to pay for procedure codes 36140, 37220, and 75710 rendered on March 27, 2023.. You 
say that this should be paid for. The Plan says that the records do not support the services billed. 
 
The CPT code manual definition of the codes at issue is: 
 
CPT 36140: 
 
Introduction of needle or intracatheter, upper or lower extremity artery 
 
CPT 37220: 
 
Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal 
angioplasty 
 
CPT 75710: 
 
Angiography, extremity, unilateral, radiological supervision and interpretation 
 
We decided that the Plan has to pay for 37220 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. 
 
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 37220 and CPT 75710. Our reviewer says that 
CPT 37220 codes for balloon angioplasty of an initial iliac artery. There is satisfactory documentation that 
balloon angioplasty of the left common iliac artery was performed with a 7 mm x 40 mm balloon for treatment 
of a significant proximal left common iliac artery stenosis on the symptomatic leg. Additionally, CPT 75710 
codes for diagnostic angiography of an extremity. This code is separately reportable from the intervention 
codes if no previous angiography is available or if there was a change in condition.  As there is no evidence 
that a previous angiogram was performed, and the enrollee has a non-healing left foot wound suggesting a 
change in condition, this code is 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 
37220 and 75710.  
 
We also decided that the Plan does not have to pay for 36140. 
 
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 for CPT 36140. Our reviewer says that this is an 
arterial access code.   Arterial access is incorporated and bundled in the billing for the intervention code that has already been 
covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 36140 have not been met. Therefore, we decided that the Plan does not have to 
pay for 36140. 
 
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.