Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 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 code 99152) and low osmolar contrast material, 300-399 mg/ml iodine concentration, per mL (CPT 
code Q9967) provided on September 8, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered 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 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 found the review indicates that 
CPT code 99152 (1 Unit) was not supported. CPT 99152 represents 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. The documentation submitted did not indicate the presence of an independent trained observer 
to assisting the monitoring of the patient's level of consciousness and physiological status; therefore, the billed 
service cannot be verified. Of note, an independent trained observer is someone other than the physician 
performing the services.  
 
Regarding CPT code Q9967 (150 units), this was not supported. The documentation submitted did indicate 
Oxilan was administered; however, the records do not support the number of units billed; therefore, the billed 
service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional 
information. The review has determined that the services were not supported in the medical records. 
 
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 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 code 99152) and 
low osmolar contrast material, 300-399 mg/ml iodine concentration, per mL (CPT code Q9967) provided on 
September 8, 2021.