Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 37229. We decided that the Plan does not have to pay 
for procedure codes 37253, 37197, and 37233.  
 
You asked the Plan to pay for procedure codes 37253, 37229, 37197, and 37233 provided on May 3, 2023. You 
say that the medical records support the billing of codes 37253, 37229, 37197, and 37233. The Plan says that 
the medical records do not support the billing of codes 37253, 37229, 37197, and 37233. 
 
We decided that the Plan has to pay for procedure code 37229.  
 
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 
code 37229 is Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial 
vessel; with atherectomy, includes angioplasty within the same vessel, when performed. 
 
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 to pay for procedure code 37229. Our reviewer says 
that the medical records support the billing of code 37229. Our physician reviewer found procedure code 37229 
is for initial tibial artery atherectomy with or without angioplasty. There is satisfactory documentation that 
tibial artery atherectomy and angioplasty, at the posterior tibial artery and tibial peroneal trunk was performed. 
Procedure code 37229 is sufficiently documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 37229 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 37229.  
 
We also decided that the Plan does not have to pay for procedure codes 37253, 37197, and 37233. 
 
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 
code 37253 is Intravascular ultrasound (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). The definition of code 37197 is Transcatheter retrieval, 
percutaneous, of intravascular foreign body (eg, fractured venous or arterial catheter), includes radiological 
supervision and interpretation, and imaging guidance (ultrasound or fluoroscopy), when performed. The 
definition of code 37233 is Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, 
unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel, when 
performed (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 to pay for procedure codes 37253, 37197, and 37233. 
Our reviewer says that the medical records do not support the billing of codes 37253, 37197, and 37233. Our 
physician reviewer found procedure code 37253 is for the supervision and interpretation of intravascular 
ultrasound (IVUS) of a noncoronary artery after initial. IVUS of an initial vessel was billed and covered. There 
is insufficient documentation of IVUS interpretation to justify additional billing.  
 
Procedure code 37233 is for additional tibial atherectomy after initial. It should be noted that the tibial-peroneal 
trunk is not considered a separate (additional) tibial artery for the purpose of billing and is incorporated in the 
code for atherectomy of the posterior tibial artery, for which coverage was recommended as noted above. There 
is no evidence that additional tibial arteries were treated and, therefore, do not recommend coverage of this 
code.  

Procedure code 37197 is a code used if a foreign body needed to be retrieved from the vascular system.  The 
interventional codes including 37225 (already covered by the plan) and 37229 (see above) is bundled to include 
required access. As the snared wire was a component of the access procedure, it is not considered a foreign 
body. Coverage of this code is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 37253, 37197, and 37233 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 37253, 37197, and 37233. 
 
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.