Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 36558 and 77001. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 76937.  
 You asked the Plan to pay for procedure codes 36558, 77001 and 76937 billed for date of service March 5, 
2023. You say that these services were necessary and were reported appropriately. The Plan says that these 
codes are not supported in the medical record. 
 
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 decided that the Plan has to pay for the services described by procedure code(s) 36558 and 77001.  
 
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). 
 
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 procedure codes 36558 and 77001. Our reviewer says that 
these codes are supported in the records provided. Our reviewer found that the record states that the catheter 
was placed in the cavoatrial junction, which meets the requirements of reporting a central venous access 
device. The record also states fluoroscopic guidance was used to place the central venous access device. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 36558 and 77001 have been met. Therefore, we decided that 
the Plan has to pay for the services described by procedure code(s) 36558 and 77001.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
76937. 
 
In this case, the CPT Code Manual definition of code 76937is 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 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 procedure code 76937. Our reviewer says that this code is 
not supported in the records provided. Our reviewer found that the record does not include evaluation of 
potential access sites or vessel patency. The criteria to report this code are not present. 
 
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 services described by procedure code(s) 76937 have not been met. 
Therefore, we decided that the Plan does not have to pay for the services described by procedure code(s) 
76937. 
 
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.