Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for selective catheter placement, arterial system; initial third 
order or more selective thoracic or brachiocephalic branch, within a vascular family (CPT code 36217), selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography 
of the ipsilateral extracranial carotid circulation and all associated radiological supervision and interpretation, 
includes angiography of the cervicocerebral arch, when performed (CPT code(s): 36222 and 36223). 
 
You asked the Plan to pay for the services. You say that these services were billed correctly for separate 
payment and are supported in the provided records. The Plan denied your request. The Plan says these services 
are not supported as billed. The Plan states code 36217 is not supported in the documentation provided and 
codes 36222 and 36223 are included in another billed code. The Plan states although these services were billed 
with a modifier for separate payment, the documentation does not support that this modifier was used 
appropriately. 
 
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 the services. Our physician reviewer found 
CPT code 36222 - Documentation submitted was reviewed and does not meet criteria. The procedure report 
describes selective catheter placement, with angiography of ipsilateral extracranial carotid circulation, 
including angiography of extracranial carotid and cervicocerebral arch performed on left side. In this case, this 
procedure would be included in CPT 36224 as it is the most comprehensive procedure, which includes the 
criteria for CPT 36222. CPT code 36223 - Procedure report describes selective catheter placement, with 
angiography of ipsilateral extracranial carotid circulation, including angiography of extracranial carotid and 
cervicocerebral arch performed on left side. In this case, this procedure would be included in CPT 36224 as it is 
the most comprehensive procedure, which includes the criteria for CPT 36223. CPT code 36217 -
Documentation submitted was reviewed and does not meet criteria.  Procedure report does not describe 
selective catheter placement, initial third order or more select thoracic or brachiocephalic. Our reviewer was 
unable to cite procedure report, as this procedure was not found in medical record, and therefore, cannot be 
verified. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for selective catheter placement, arterial system; initial third order or more selective thoracic or 
brachiocephalic branch, within a vascular family (CPT code 36217), selective catheter placement, common 
carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral extracranial carotid 
circulation and all associated radiological supervision and interpretation, includes angiography of the 
cervicocerebral arch, when performed (CPT code(s): 36222 and 36223).