Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the angiography (75716-59) and anesthesia services (99152, 
99153) provided on September 7, 2021. 
 
You asked the Plan to pay for the angiography and anesthesia services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says these services have denied 
correctly. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
In this case, the CPT Code Manual definition of code 75716 is angiography, extremity, bilateral, radiological 
supervision and interpretation. 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 aged 5 years or older. The CPT Code Manual definition of code 99153 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; each 
additional 15 minutes intraservice time (List separately in addition to code for primary service). 
 
We find that CPT codes 99152 and 99153 are not supported in the medical records. Specifically, these codes 
refer to an independent observer being present when these services were rendered. There was no evidence 
provided of an independent observer being present. 
 
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 angiography and anesthesia services Our 
reviewer says that the documentation does not support the use of the -59 modifier with the services coded 
75716. Our physician reviewer found the enrollee is a 72-year-old man with vascular disease. On September 7, 
2021, right external iliac artery access was obtained, a pelvic arteriogram with bilateral lower extremity runoff, 
and closure with Angio-Seal closure device were performed. In this case, 75630 and 75716 cannot be coded 
together. 75630 is for single catheter placement in the aorta with extremity run off. The use of the -59 modifier 
is not supported. 
 
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 angiography and anesthesia services have not been met. Therefore, we 
decided that the Plan does not have to pay for the angiography (75716-59) and anesthesia services (99152, 
99153) provided on September 7, 2021.