Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravascular ultrasound during diagnostic evaluation and/or 
therapeutic intervention (37252), intravascular ultrasound (noncoronary vessel) during diagnostic evaluation 
and/or therapeutic intervention, each additional noncoronary vessel (37253) and primary percutaneous 
transluminal mechanical thrombectomy (37184) provided on April 3, 2023. 
 
You asked the Plan to pay for outpatient procedures. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says procedure codes 37184, 
37252, 37253 are not supported by the medical records submitted. 
 
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 coder 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 outpatient procedures. Our reviewer says that the requested 
services do not meet criteria for approval. Our reviewer found that for CPT 37252, procedure report documents 
"intravascular ultrasound (IVUS) evaluation of the right external iliac artery to ataxia telangiectasia (AT) was 
performed".  Per Codify, " in this add-on procedure, the provider inserts a specially designed catheter with an 
ultrasound transducer, a device that sends high-frequency sound waves through the tissues and detects their 
returning echoes to provide information about the underlying structures, into the vessel and examines its 
interior during a diagnostic or interventional therapeutic procedure, such as stent placement to treat an 
obstruction or blockage. This procedure is for the first vessel that is not a heart vessel (noncoronary) and 
includes radiologic supervision and interpretation of the intravascular ultrasound". In this case, procedure 
report does not include sufficient documentation to confirm procedure has been performed. For CPT 37253, 
procedure report documents "IVUS evaluation of the right external iliac artery to AT was performed".  Per 
Codify " In this add-on procedure, the provider inserts a specially designed catheter with an ultrasound 
transducer, a device that sends high-frequency sound waves through the tissues and detects their returning 
echoes to provide information about the underlying structures, into the vessel and examines its interior during a 
diagnostic or interventional therapeutic procedure, such as stent placement to treat an obstruction or blockage. 
This procedure is for the first vessel that is not a heart vessel (noncoronary) and includes radiologic supervision 
and interpretation of the intravascular ultrasound". In this case, procedure report does not include sufficient 
documentation to confirm procedure has been performed. For CPT 37184, procedure report does not include 
sufficient documentation to confirm procedure has been performed. Procedure report documents "Catheter 
directed thrombectomy of the distal at was performed to improve flow". The provider treats an occlusion, or 
blockage, in a noncoronary or non-intracranial artery or in an arterial bypass graft by using a combined 
technique of mechanical thrombectomy and pharmacological thrombolytic injection. He also uses fluoroscopic 
guidance to perform mechanical thrombectomy. In this case there is insufficient documentation to verify 
procedure code billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of outpatient procedures have not been met. Therefore, we decided that the Plan 
does not have to pay for intravascular ultrasound during diagnostic evaluation and/or therapeutic intervention 
(37252), intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic 
intervention, each additional noncoronary vessel (37253) and primary percutaneous transluminal mechanical 
thrombectomy (37184) provided on April 3, 2023.