Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37228. We decided that the Plan does not have to pay for the rest of the 
codes.  
 
You asked the Plan to pay for procedure codes 36140, 36245, 36246, 37228, 37252, 37253, 75710 rendered on 
May 3, 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 37228.  
 
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 37228 is 
"Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with 
transluminal angioplasty." 
 
We asked our coding 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 37228. Our reviewer says that the records do 
support the use 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 
37228.  
 
We also decided that the Plan does not have to pay for the rest of the codes. 
 
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 the rest of the codes is: 
 
CPT 36140: 
 
Introduction of needle or intracatheter, upper or lower extremity artery 
 
CPT 36245: 
 
Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery 
branch, within a vascular family 
 
CPT 36246: 
 
Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery 
branch, within a vascular family 
 
CPT 37252: 
 
Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, 
including radiological supervision and interpretation; initial noncoronary vessel (List separately in addition to 
code for primary procedure) 
 
CPT 37253: 
 
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) 
 
CPT 75710: 
 
Angiography, extremity, unilateral, radiological supervision and interpretation 
 
We asked our coding 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 these codes.  
 
Our reviewer says that CPT 36140 is not supported. This procedure is part of and included in the main 
procedure, it should not be reported separately according to CPT and NCCI rules. 
 
Additionally, CPT 36245, 36246, and 75710 are not supported as separately identifiable procedures. These 
procedures are included in the revascularization and angioplasty procedure performed during this encounter. 
According to CPT and NCCI rules, they cannot be reported separately in this case. 
 
Finally, CPT 37252 and 37253 are not supported. The procedure report does not mention an intravascular 
ultrasound performed during this encounter. 
 
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 rest of the codes have not been met. Therefore, we decided that the Plan 
does not have to pay for the rest of the codes. 
 
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.