Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional percutaneous transluminal mechanical 
thrombectomy and/or infusion (36906), additional ultrasound guidances for vascular access (76937 x2), and 
additional moderate sedation services (99152) provided on December 20, 2021. 
 
  You asked the Plan to pay for the additional thrombectomy, additional ultrasound guidances, and additional 
moderate sedation services. You say that the enrollee had multiple exams on this date of service. The Plan 
denied your request. The Plan says the medical records provided contain two procedure reports, but these 
reports are duplicate. The Plan also says that there is no indication that a second procedure was performed on 
this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate Current Procedural Terminology (CPT) code. 
 
In this case, the CPT Code Manual definition of code 36906 is Percutaneous transluminal mechanical 
thrombectomy and/or infusion for thrombolysis. The CPT Code Manual definition of code 76937 is 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. The CPT Code Manual definition of code 99152 is Moderate sedation services 
provided by the same physician or other qualified health care professional performing the diagnostic or 
therapeutic service that the sedation supports, requiring the presence of an independent trained observer to 
assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of 
intraservice time, patient age 5 years or older. 
 
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 additional thrombectomy, additional ultrasound 
guidances, and additional moderate sedation services. Our reviewer says that the additional thrombectomy, 
ultrasound guidances, and moderate sedation services are not supported in the medical records. Our reviewer 
found there is only one unit of conscious sedation provided on December 20, 2021. Our reviewer found that 
based upon the report only one of each of the disputed procedures was done on December 20, 2021. Our 
physician reviewer also found that if reimbursement was done for the elements described above the disputed 
claim is a duplicate. 
 
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 additional thrombectomy, additional ultrasound guidances, and additional 
moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for an 
additional percutaneous transluminal mechanical thrombectomy and/or infusion (36906), additional ultrasound 
guidances for vascular access (76937 x2), and additional moderate sedation services (99152) provided on 
December 20, 2021.