Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for code 93312. We decided that the Plan does not have to pay for codes 
93503, 93320, 93325, and 76376.  
 
You asked the Plan to pay for codes 76376, 93312, 93320, 93325, and 93503 billed for June 16, 2023. You say 
that these services were billed correctly. The Plan says that these services are not documented. 
 
 We decided that the Plan has to pay for code 93312.  
 
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 93312 is echocardiography, transesophageal, real-time 
with image documentation (2D) (with or without M-mode recording); including probe placement, image 
acquisition, interpretation and report. 
 
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 item/service at issue. Our reviewer says 
that code 93312 is supported in the records. Our physician reviewer found the medical record includes 
documentation of echocardiography, transesophageal, real-time with image documentation (2D) (with or 
without M-mode recording); including probe placement, image acquisition, interpretation and report. 
 
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 service at issue have been met. Therefore, we decided that the Plan has to 
pay for code 93312.  
 
We also decided that the Plan does not have to pay for codes 93503, 93320, 93325, and 76376. 
 
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 93503 is insertion and placement of flow directed 
catheter (eg, Swan-Ganz) for monitoring purposes. The definition of 93320 is doppler echocardiography, 
pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for 
echocardiographic imaging); complete. The definition of 93325 is doppler echocardiography color flow 
velocity mapping (List separately in addition to codes for echocardiography). The definition of 76376 is 3D 
rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, 
or other tomographic modality with image postprocessing under concurrent supervision; not requiring image 
postprocessing on an independent workstation. 
 
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 item/service at issue. Our reviewer says 
that codes 93503, 93320, 93325, and 76376 are not supported in the records. Our physician reviewer found the 
procedure report does not include documentation of insertion and placement of flow directed catheter to 
support code 93503. It also does not include documentation of doppler echocardiography color flow velocity 
mapping or pulsed wave and/or continuous wave with spectral display for codes 93325 and 93320 respectively. 
The record does not include documentation of 3D rendering with interpretation and reporting of computed 
tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing under concurrent supervision to support code 76376.  
 
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 services at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 93503, 93320, 93325, and 76376. 
 
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.