Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic services provided to the enrollee on January 22, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
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 the denied codes is: 
 
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) 
 
CPT 93312: 
 
Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode 
recording) 
 
CPT 93320: 
 
Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in 
addition to codes for echocardiographic imaging); complete 
 
CPT 93325: 
 
Doppler echocardiography color flow velocity mapping (List separately in addition to codes for 
echocardiography) 
 
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 the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
medical records provided does not include documentation of 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) (CPT 76937) being performed on January 22, 2020, 
therefore this service cannot be verified. The medical records provided does not include documentation of CPT 
93312-26-59 - Echocardiography, transesophageal, real-time with image documentation (2D) (with or without 
M-mode recording) being performed on January 22, 2020 therefore, this service cannot be verified. The 
medical records do not include documentation of a Doppler echocardiography, pulsed wave and/or continuous 
wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete (CPT 
93320) being performed on January 22, 2020 therefore this service cannot be verified. The medical records 
provided does not include documentation of a Doppler echocardiography color flow velocity mapping (List 
separately in addition to codes for echocardiography) (CPT 93325) being performed therefore, this service 
cannot be verified. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for diagnostic services provided to the enrollee on January 22, 2020.