Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (Current Procedural Terminology 
(CPT) code(s): 99152 and 99153) provided on October 12, 2021. 
 
You asked the Plan to pay for the anesthesia 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. 
 
In this case, the CPT Code Manual definition of code 99152 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; initial 15 minutes of intraservice time, patient age 
5 years or older and code 99513 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 find that CPT code [Enter billing code at issue (e.g. 43856, K0002, etc.)] is not supported in the medical 
record. CPT code 99152 (1 Unit) remains 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 assist in 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. It is noted that multiple attempts were made to 
contact the provider for additional information. 
 
CPT code 99153 (2 units) remains not supported. The required primary service code (CPT code 99152) is 
denied in the claim processing system (Reason Code 191); therefore, this service cannot be reimbursed 
separately. The documentation submitted did not indicate the presence of an independent trained observer to 
assist in 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. It is noted that multiple attempts were made to contact the provider for additional 
information. Based on this information, we decided that Medicare rules for coverage of the anesthesia services 
have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services 
(Current Procedural Terminology (CPT) code(s): 99152 and 99153) provided on October 12, 2021.