Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the various surgical and anesthesia services provided to the 
enrollee from September 1, 2021, to September 16, 2021. 
 
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 are not supported in the medical records submitted. 
 
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 36245: 
 
Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery 
branch, within a vascular family 
 
 
 CPT 37243: 
 
Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural 
roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or 
infarction 
 
CPT 75726: 
 
Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision 
and interpretation 
 
CPT 75774: 
 
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and 
interpretation (List separately in addition to code for primary procedure) 
 
CPT 99152: 
 
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 
 
CPT 99153: 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the documentation does not clarify 
which procedures are being denied for which date of service. CPT 36245 cannot be verified for unbundling. In 
terms of CPT 37243 for September 1, 2021, this is an incorrect procedure code to report, as technetium 99m is 
not an embolic agent, and therefore cannot be verified. For September 16, 2021, the documentation states "Y90 
radioembolization" This is the incorrect procedure code to report for service provided. In terms of CPT 75726 
and 75774, these are procedures are not supported, as the procedures are inclusive to the primary procedure if 
reported correctly. In terms of CPT 99152 and 99153, these procedures cannot be verified as unbundled. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the various surgical and anesthesia services provided to the enrollee from September 1, 2021, to 
September 16, 2021.