Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 36225. We decided that the 
Plan does not have to pay for the services described by procedure code(s) 36222.  
 
You asked the Plan to pay for procedure codes 36225-59-50 and 36222-59-50 provided on May 26, 2023.  You 
say that the medical records support procedure codes 36225 and 36222 as separate and distinct from procedure 
codes 36226 and 36223. The Plan says that the medical records do not support procedure codes 36225 and 
36222 as separate and distinct from procedure codes 36226 and 36223. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 36225.  
 
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 36225 is a column II code to column I code 36226; however,  
36225 was billed with a modifier.  
 
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 services described by procedure code(s) 36225. Our 
reviewer says that the medical records support procedure code 36225 as separate and distinct from procedure 
code 36226. Our coder found the medical documentation supports the use of procedure code 36225, as the 
records show the subclavian artery was reviewed with angiography. The use of modifier 59 is supported.  
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services described by procedure code(s) 36225 have been met. Therefore, 
we decided that the Plan has to pay for the services described by procedure code(s) 36225.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
36222. 
 
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 36222 is a column II code to column I code 36223; however,  
36222 was billed with a modifier. 
 
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 services described by procedure code(s) 36222. Our 
reviewer says that the medical records do not support procedure code 36222 as separate and distinct from 
procedure code 36223. Our coder found the medical documentation does not support the use of procedure code 
36222, as the records show this code in included with procedure code 36223. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services described by procedure code(s) 36222 have not been met. 
Therefore, we decided that the Plan does not have to pay for the services described by procedure code(s) 
36222.  
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.