Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 75716. We decided that the Plan does not have to pay for 37229 and 
37253.  
 
You asked the Plan to pay for procedure codes 37229, 37253, and 75716 rendered on January 5, 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 75716.  
 
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 75716 is "Angiography, extremity, bilateral, 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 75716. Our reviewer says that this codes for 
supervision and interpretation of bilateral extremity angiography. This is separately billable if there are no 
available recent angiograms and there is satisfactory documentation of findings. In this case, there is no 
evidence of recent prior angiography, and the description of findings are satisfactory to justify use and 
coverage of this code 
 
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 
75716.  
 
We also decided that the Plan does not have to pay for 37229 and 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 
the rest of the billed codes is: 
 
CPT 37229: 
 
Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with 
atherectomy, includes angioplasty within the same vessel, when performed 
 
CPT 37253: 
 
Intravascular ultrasound (IVUS) (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 37229 and CPT 37253. Our reviewer says that 
CPT 37229 codes for tibial atherectomy. The tibial artery atherectomy could not be successfully completed 
with plans for the enrollee to likely return for retrograde access that, if successful can be billed and potentially 
covered at that time.  Attempted but unsuccessful procedures are not billable. CPT 37253 codes for the 
supervision and interpretation of IVUS imaging of an additional vessel after an initial vessel. The health plan 
has already covered IVUS of the initial vessel; however, there is no satisfactory documentation of findings of 
additional IVUS imaging to justify additionally billing and coverage.  
 
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 and 37253 have not been met. Therefore, we decided that the Plan does 
not have to pay for 37229 and 37253. 
 
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.