Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 75726 and 75774. We decided that the Plan does not 
have to pay for procedure code 99153.  
 
You asked the Plan to pay for procedure codes 75726, 75774 and 99153 billed for date of service June 17, 
2022. You say that these services were necessary and were reported appropriately. The Plan says that these 
services are not supported as billed. 
 
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 procedure codes 75726 and 75774.  
 
In this case, we have confirmed that codes 75726 and 75774 are both column II codes to column I code 37242; 
however, codes 75726 and 75774 were each billed with a modifier.  
 
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 75726 and 75774. Our reviewer says that 
the use of the 59 modifier with these codes is appropriate in this case. Our reviewer found that these procedures 
are separately identifiable as procedure code 37242 was performed due to a splenic aneurysm. The selective 
angioplasty services were performed on a different area of the body as separate procedures. 
 
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 75726 and 75774 have been met. Therefore, we decided that 
the Plan has to pay for procedure codes 75726 and 75774.  
 
We also decided that the Plan does not have to pay for procedure code 99153. 
 
In this case, 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 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 99153. Our reviewer says that the reporting 
of two units of code 99153 is not supported in this case. Our reviewer found that the medical records do not 
support the use of this code. 
 
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 code 99153 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99153. 
 
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.