Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37220 and 75716. We decided that the Plan does not have to pay for 
36247 and 75630.  
 
You asked the Plan to pay for procedure codes 36247, 37220, 75630, and 75716 rendered on September 26, 
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 37220 and 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 the overturned codes is: 
 
CPT 37220: 
 
Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal 
angioplasty 
 
CPT 75716: 
 
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 these codes. Our reviewer says that CPT 37220 
codes for iliac artery angioplasty. There is satisfactory documentation that iliac artery stenosis was identified 
on angiogram and was angioplastied. CPT 75716 codes for diagnostic angiography of the lower extremities 
bilaterally. This work is separately billable from the lower extremity intervention code if there is no recent 
prior angiogram, and the results are used to plan to intervention. In this case there is no evidence of a recent 
angiogram and there is satisfactory documentation of the angiographic interpretation; the use and billing of this 
code is justified. 
 
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 
37220 and 75716.  
 
We also decided that the Plan does not have to pay for 36247 and 75630. 
 
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 upheld 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 75630: 
 
Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, 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 the upheld codes. Our reviewer says that CPT 
36247 is a catheterization code that is bundled into the lower extremity intervention code, in this case CPT 
37225. This code has been billed and covered. CPT 36247 is not separately billable. CPT 75630 codes for 
diagnostic aortogram with runoff.  
 There is an inadequate description of aortic findings and the work performed in interpreting bilateral lower 
extremity runoff overlaps/reproduces the interpretation of bilateral lower extremities. 
 
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 and 75630 have not been met. Therefore, we decided that the Plan does 
not have to pay for 36247 and 75630. 
 
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.