Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 31500, 36556, 76937 and 99291. We decided that the 
Plan does not have to pay for procedure code 99292.  
 
You asked the Plan to pay for procedure codes 31500, 36556, 76937, 99291 and 99292 billed for date of 
service June 11, 2022.. You say that you have billed the services at issue correctly. The Plan says that the 
provided records do not support the services billed. 
 
We decided that the Plan has to pay for procedure codes 31500, 36556, 76937 and 99291.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 procedure codes 31500, 36556, 76937 and 
99291. Our reviewer says that procedure codes 31500, 36556, 76937 and 99291 meet criteria for payment. Our 
physician reviewer found that the provided procedure report describes: an emergency intubation performed for 
respiratory failure (31500); an emergent Insertion of non-tunneled centrally inserted central venous catheter, 
age 5 years or older (36556); and ultrasound guidance for vascular access (76937). Therefore, these codes 
should be covered.  
 
In this case, we have confirmed that code 99291 is a column II code to column I codes 31500 and 36556; 
however, code 99291 was billed with a modifier. Our physician reviewer found that the procedure report 
supports that the critically ill enrollee presented to the emergency department. The provider documents the time 
spent engaged in work directly related to patient care, including bedside assessment, supervision of care and 
interpretation of diagnostic tests, as well as intervention services. Procedure code 99291 should be covered.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 31500, 36556, 76937 and 99291 have been met. Therefore, we 
decided that the Plan has to pay for procedure codes 31500, 36556, 76937 and 99291.  
 
We also decided that the Plan does not have to pay for procedure code 99292. 
 
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, we have confirmed that code 99292 is a column II code to column I codes 31500 and 36556. This 
claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99292. 
 
  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.