Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 36558 and 76937. We decided that the Plan does not have to pay for 
99223.  
 
You asked the Plan to pay for procedure codes 36558, 76937, and 99223 rendered on April 14, 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 36558 and 76937.  
 
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 overturned codes is: 
 
CPT 36558: 
 
Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years 
or older 
 
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) 
 
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 36558 
codes for a tunneled central venous catheter. There is satisfactory documentation that the catheter was both 
tunneled and placed centrally, specifically at the atrial-caval junction. 
 
In terms of CPT 76937, this codes for ultrasound guidance for vascular access. There is satisfactory 
documentation that ultrasound guidance was used to access the jugular vein. While there is a stipulation that 
the images must be archived, it is not reasonable to require documentation of this in the operative note. 
 
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 
36558 and 76937.  
 
We also decided that the Plan does not have to pay for 99223. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
definition of CPT 99223 is "Initial hospital inpatient or observation care, per day, for the evaluation and 
management of a patient, which requires a medically appropriate history and/or examination and high level of 
medical decision making. When using total time on the date of the encounter for code selection, 75 minutes 
must be met or exceeded." 
 
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 CPT 99223 with modifier 25. Our reviewer says 
that this code is used for the highest-level inpatient evaluation and management possible. There is inadequate 
documentation that the work performed to justify this code was performed and it suggests the majority of the 
time spent was on the consent process for the procedure. This work would be bundled into the main procedure 
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 99223 have not been met. Therefore, we decided that the Plan does not have to 
pay for 99223. 
 
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.