Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for selective catheter placement (36247), radiopharmaceutical therapy 
(79445), initial moderate sedation services (99152), and vascular embolization or occlusion (37243) provided 
on August 18, 2021. 
 
You asked the Plan to pay for selective catheter placement, radiopharmaceutical therapy, initial moderate 
sedation services, and vascular embolization or occlusion. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that there is no separate payment for the 
services at issue. 
 
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 also say that Medicare health plans 
must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision 
to deny coverage or payment. 
 
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 selective catheter placement, radiopharmaceutical therapy, 
and initial moderate sedation services. Our reviewer says that the billed codes 36247, 794445, and 99152 meet 
criteria for reimbursement. Our reviewer found that, regarding CPT code 36247, selective catheter placement 
would be reported separately from CPT code 37241. It is appropriate to bill for all catheter placements 
performed during this procedure. Regarding CPT code 79445, radiopharmaceutical therapy is documented in 
the operative report, and it is appropriate to report chemotherapy separate from vascular embolization 
procedures. Regarding CPT code 9915, the operative report includes documentation of moderate sedation with 
the presence of an independent trained observer to assist in the monitoring of the enrollee's level of 
consciousness and physiological status. Time was documented to support this procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of selective catheter placement, radiopharmaceutical therapy, and initial moderate 
sedation services have been met. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request for vascular embolization or occlusion.  The case record does not explain why CPT code 37243 was denied. It is the Plans responsibility to substantiate 
their denial. In the absence of an explanation, we must find in your favor regarding vascular embolization or 
occlusion. Therefore, we decided that the Plan has to pay for selective catheter placement (36247), 
radiopharmaceutical therapy (79445), initial moderate sedation services (99152), and vascular embolization or 
occlusion (37243) provided on August 18, 2021.  
 
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.