Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36247, 36248, 37225, 37229, 37233, 75625, 
75716, 76937, 99152, and 99153 rendered on January 11, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes are not supported in the 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 36247: 
 
Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family 
 
CPT 36248: 
 
Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, 
pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or 
third order vessel as appropriate) 
 
CPT 37225: 
 
Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with 
atherectomy, includes angioplasty within the same vessel, when performed 
 
CPT 37229: 
 
Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with 
atherectomy, includes angioplasty within the same vessel, when performed 
 
CPT 37233: 
 
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) 
 
CPT 75625: 
 
Aortography, abdominal, by serialography, radiological supervision and interpretation 
 
CPT 75716: 
 
Angiography, extremity, bilateral, radiological supervision and interpretation 
 
CPT 75774: 
 
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and 
interpretation (List separately in addition to code for primary procedure) 
 
CPT 76937: 
 
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) 
 
CPT 99152: 
 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intraservice time, patient age 5 years or older 
 
CPT 99153: 
 Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; each additional 15 minutes intraservice time (List separately in addition to code for 
primary service) 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the one page of the operative 
report does not sufficiently satisfy the proper documentation needed to be able to verify any of the procedure 
codes that were performed. None of the procedure codes could be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 36247, 36248, 37225, 37229, 37233, 75625, 75716, 76937, 99152, and 99153 
rendered on January 11, 2023.