Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded as 36558, 77001, 76937, 99152 provided on March 18, 2021.
You asked the Plan to pay for the medical services. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says the records do not corroborate the codes as billed.
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 36558 is insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older. The CPT Code Manual definition of code 77001 is fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 76937 is 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). The CPT Code Manual definition of code 99152 is 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. 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 medical services. Our reviewer says that the documentation submitted do not support the codes as billed. Our reviewer found that the medical records provided do not included sufficient documentation to validate that an insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older was performed on March 18, 2021, therefore this procedure cannot be verified. The medical records also do not include sufficient documentation to validate that fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure) was performed on March 18, 2021, therefore this service cannot be verified. The medical records provided do not include sufficient documentation to validate that an 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) was performed on March 18, 2021, therefore this service cannot be verified. Finally, the medical records provided does not include sufficient documentation to validate that 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 was performed on March 18, 2021, therefore this service cannot 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 medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 36558, 77001, 76937, 99152 provided on March 18, 2021.