Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the pelvic ultrasound (76856). We decided that the Plan does not have 
to pay for the three dimensional (3D) rendering with interpretation (76376) and vascular study (93975).  
 
You asked the Plan to pay for the pelvic ultrasound (76856), three dimensional (3D) rendering with 
interpretation (76376), and vascular study (93975) provided on March 3, 2022. You say that you are not 
responsible for the amount you are being billed for. The Plan says that the notes show that a transvaginal 
ultrasound was necessary however it is unclear why the other tests were ordered. 
 
  We decided that the Plan has to pay for the pelvic ultrasound (76856).  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 pelvic ultrasound (76856). Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found you had a transabdominal and transvaginal pelvic ultrasound for post-menopausal 
bleeding on March 3, 2022. Our reviewer found that this was an indicated and medically necessary exam and 
should be approved. 
 
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 pelvic ultrasound (76856) have been met. Therefore, we decided that the 
Plan has to pay for the pelvic ultrasound (76856).  
 
We also decided that the Plan does not have to pay for the three dimensional (3D) rendering with 
interpretation (76376) and vascular study (93975). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 3D rendering with interpretation (76376) 
and vascular study (93975). Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found current procedural terminology (CPT) 
code 93975 for analyzing vascular flow is not only unnecessary, but it is not documented in the report. Our 
reviewer found that a charge for 3D rendering was billed and claims the 3D rendering was necessary and done. 
Our physician reviewer found that this service is not documented in the report, was not necessary, and should 
be denied. 
 
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 3D rendering with interpretation (76376) and vascular study (93975) have 
not been met. Therefore, we decided that the Plan does not have to pay for the three dimensional (3D) 
rendering with interpretation (76376) and vascular study (93975). 
 
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.