Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 76937. We decided that the Plan does not have to pay for 36247.  
 
You asked the Plan to pay for procedure codes 36247 and 76937 rendered on September 12, 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 76937.   
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 76937 is "Ultrasound 
guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of 
selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent 
recording and reporting (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 76937. Our reviewer says that this codes 
ultrasound guidance for vascular access. In this case, there is satisfactory documentation of left femoral artery 
needle access under ultrasound guidance. Therefore, there is satisfactory documentation that the work done to 
justify use of this code has been performed. While images must be properly archived, it is not reasonable to 
require that this be specifically documented in the operative report. 
 
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 
76937.  
 
We also decided that the Plan does not have to pay for 36247. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 36247 is "Selective 
catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity 
artery branch, within a vascular family." 
 
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 36247. Our reviewer says that this codes for 
selective arterial catheterization. When a lower extremity intervention such as atherectomy or angioplasty is 
performed, the selective access is bundled in with that intervention code and is not separately billable. 
 
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 have not been met. Therefore, we decided that the Plan does not have to 
pay for 36247. 
 
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.